Stable Angina, Acute Coronary Syndrome, Aortic Dissection Flashcards
What is Stable Angina?
Chest pain/pressure for at least 2 months that is provoked by exertion or stress
Chest pain/pressure for at least 2 months that is provoked by exertion or stress
Stable Angina
What are the 3 options of Acute Coronary Syndrome?
- Unstable Angina
- NSTEMI
- STEMI
What is Unstable Angina?
New onset angina with minimal exertion or with rest or with increased frequency/severity
What is a NSTEMI?
ST segment depression with possible T wave inversion and ABNORMAL cardiac enzymes
What is a STEMI?
ST segment elevation with ABNORMAL cardiac enzymes
– or new LBBB or posterior MI
ST depression and/or T wave inversion with NORMAL cardiac enzymes
Unstable Angina
Coronary Artery Disease is the leading cause of death in the US. What are some modifiable risk factors?
Hypertension, Hyperlipidemia, obesity, smoking, diabetes, stress
Coronary Artery Disease is the leading cause of death in the US. What are some non-modifiable risk factors?
Increasing male age, ethnicity, family history
What are 3 other risk factors for Coronary Artery Disease?
CKD
Proteinuria
Inflammatory conditions
What are 3 other risk factors for CAD?
CKD
Proteinuria
Inflammatory conditions
What is the classic presentation of Acute Coronary Syndrome (unstable angina/NSTEMI/STEMI)?
- Chest pain that radiates to shoulder/arm/neck/jaw
- Dyspnea and N/V
- Sweating and fatigue
Atypical or silent (painless) Acute Coronary Syndrome occurs more commonly in what populations?
Elderly
Women
Diabetics
Typical Angina chest pain criteria?
- ALL 3 *
1. Substernal chest pain/discomfort
2. Provoked by exertion or emotional stress
3. Relieved by rest and/or Nitroglycerin
Atypical Angina chest pain criteria?
- 2/3 *
1. Substernal chest pain/pressure
2. Provoked by exertion or emotional stress
3. Relieved by rest and/or Nitroglycerin
NON-Angina chest pain criteria?
- < or equal to 1 *
1. Substernal chest pain/pressure
2. Provoked by exertion or emotional stress
3. Relieved by rest and/or Nitroglycerin
In order to diagnose Stable Angina, what should be performed first?
ECG and pretest probability of CAD
In order to diagnose Stable Angina, if the pretest probability of CAD is intermediate, what are the 2 options for the patient?
- If able to exercise = Exercise ECG and ECHO
- If unable to exercise = Pharmacologic testing
== BOTH: Coronary Angiography
In order to diagnose Stable Angina, if the pretest probability of CAD is high, what is the next step?
Medical therapy and Coronary Angiography
What are some types of Cardiac Stress testing?
- Exercise ECG
- Dobutamine ECHO
- MPI (myocardial perfusion imaging)
When can you not use an Exercise ECG?
In patients with baseline ECG abnormalities
What does the Dobutamine ECHO evaluate?
Contractility
What does a MPI (myocardial perfusion imaging) do?
Uses vasodilators to add stress to the heart in patients who cannot exercise for cardiac stress testing
In order to diagnose Acute Coronary Syndrome (unstable angina/NSTEMI/STEMI), what are the options?
ECG
Cardiac biomarkers
Coronary Angiography
STEMI ECG changes
ST elevation of > 2 mm or new LBBB
STEMI involves ____ occlusion
Complete
You cannot diagnose a STEMI in the setting of?
Old/known LBBB
NSTEMI ECG changes
New ST depression, T wave inversion > 1 mm with a R/S ratio > 1
NSTEMI involves ____ occlusion
Partial
– or if a complete occlusion, there are collaterals developed
What 3 therapies improve mortality of CAD?
Beta blockers
Aspirin
ACEi
What are treatment options for Stable Angina?
- Lifestyle modifications, aspirin, statin
- Beta and Calcium blockers
- Nitrates, Ranolazine
What is the initial treatment of Acute Coronary Syndrome?
MONA
- Morphine
- Oxygen
- Nitrates
- Aspirin
What Anti-platelet therapies are available for Acute Coronary Syndrome?
Aspirin
P2Y12 inhibitors
Anti-coagulation (Heparin)
For a STEMI, what is a specific anti-coagulation medication?
Tissue-plasminogen (+)
For Acute Coronary Syndrome, what are the 2 options for revascularization therapy?
PCI - percutaneous coronary intervention
CABG - coronary a. bypass graft
If a patient is having a STEMI and they need PCI, what should you do within 90 minutes and within 120?
90 - PCI if available
120 - transfer to a facility that does it
What are the 3 main arteries that come off the aortic arch?
Brachiocephalic – R. subclavian and R. common carotid
Left common carotid
Left subclavian
Stanford Type A Aortic Dissection
Tear in the Ascending Aorta
Stanford Type B Aortic Dissection
Tear in the Descending Aorta
Which type of Stanford Aortic Dissection is more common and more deadly?
Type A
What are some risk factors for Aortic Dissection, that are sometimes seen in younger patients?
- CT disorders – marfans and ehlers danlos
- Syphilis
- Cocaine/meth and trauma
What are some risk factors for Aortic Dissection?
Hypertension, dyslipidemia, smoking
Most common complaint with Aortic Dissection?
Tearing/ripping chest pain
What other cardiovascular symptoms/signs can be seen with Aortic Dissection?
BP asymmetry, pulse deficits
Cardiac tamponade, MI
Syncope
What is seen on CXR with Aortic Dissection?
Widened Mediastinum
What is the most common method to diagnose Aortic Dissection?
CT angiography
What is the treatment for Aortic Dissection and its purpose?
Anti-impulse therapy to decrease HR/force in order to decrease stress on intima of aorta
- BP < 120
- HR < 60
Besides Anti-impulse therapy, what are the options of treatment for Aortic Dissection?
Opiates for pain control
Surgery
Surgical intervention for Aortic Dissection has _____ survival rates
Better
What is the way to diagnose an Aortic Dissection?
CT Angiography
Inferior MI leads and vessel affected
Leads 2, 3, AVF
RCA vessel
Septal MI leads and vessel affected
Leads V1 and V2
LAD vessel
Anterior MI leads and vessel affected
Leads V2 - V4
LAD vessel
Lateral MI leads and vessel affected
Leads 1, AVL, V5 and V6
Left circumflex vessel
Posterior MI leads affected
Tall R waves and ST depression in V1-V3
