What are the coronary syndromes leading to chest pain?
Angina, Acute Coronary Syndromes, Coronary Spasm, Acute MI
What are the non coronary causes of chest pain?
Pericarditis, Aortic Dissection, Mitral Valve Prolapse, Pulmonary Hypertension, Chest Trauma, Radiation Therapy, and Aortic Valve Disease
What are the non-cardiac causes of chest pain?
Pulmonary Embolus, GERD, Neurological (Herpes Zoster), Musculoskeletal (Trauma), and Psychiatric (anxiety)
What are the clinical features of CAD?
Coronary Artery Disease is asymptomatic and has stable angina pectoris. This can lead to sudden death and is associated with Acute Coronary Syndromes.
What are the Acute Coronary Syndromes?
Unstable Angina Pectoris, Non ST Elevation Acute MI, ST Elevation Acute Myocardial Infarction
Discuss Asymptomatic Ischemia:
Episodes of this occur in 25-50% of patients with each type of coronary syndromes. Asymptomatic can outnumber symptomatic by 20:1. This is more common in diabetics and the elgerly.
Discuss Sudden Cardiac Death:
Accounts for approximately 325,000 deaths per year. This is often the first expression of CAD and responsible for 50% of the CAD deaths. Men 3:1.
The proportion of sudden deaths decrease with age.
What are the classical signs/symptoms of Angina Pectoris?
Left precordial pain, constrictive in type, radiating to left arm and fingers.
What are the atypical signs of Angina Pectoris?
Precordial pain without radiation. Toothaches, epigastric pain, cervical pain, jaw pain, dizziness, diaphoresis, nausea, and dyspnea.
Which populations are more likely to present with atypical vs. typical angina?
Men more typical while women are more atypical
What are the classes of Angina?
Class I- Only strenuous exercise causes angina
Class II- There are slight limitations to ordinary activities such as walking uphill or climbing stairs (2 or more blocks, more than 1 flight of stairs)
Class III- There are marked limitations and angina develops after walking less than 2 blocks or climbing one flight of stairs
Class IV- There is an inability to conduct activities of daily life
What is the clinical relevance of Perfusion Pressure?
Hypotension and shock decrease perfusion pressure and can cause angina.
What is the clinical relevance of Coronary Vascular Resistance?
Increased coronary resistance causes spasm and angina
What is the clinical relevance of the Diastolic Filling Period?
A rapid tachycardia shortens diastole and decreases perfusion.
Discuss Coronary Spasm:
Chest pain associated with ST-segment elevation. There is a constriction of epicardial coronaries that contain a preponderance of constrictor receptors, adrenergic alpha receptors.
Most episodes are in the morning due to focal coronary artery vasospasm
What is the pathophysiology of a coronary spasm?
An abnormality of normal vasodilator function within the coronary arteries and/or a hypersensitivity of the coronary arteries to normal mediators of vasoconstriction.
What determines Myocardial Oxygen Demand?
Heart Rate, Muscle Mass, Contractile Force, and Wall Tension.
Wall Tension is made of IV pressure, ventricular radius and ventricular wall thickness.
So in general, what causes stable angina?
A decreased supply of O2 coupled with an increased demand for it.
What are the pathophysiological consequences of Myocardial Ischemia?
Transient Reduction in Ventricular Compliance (S4).
Elevated LV End-Diastolic Pressure
Decreased resting membrane potential
Develop post-repolarization refractoriness
Decreased conduction velocity
Loss of ICF K+ and an Increase in ECF K+
What are the three ways myocardial ischemia is detected?
1. Electrophysiological Effects
2. Disturbances in Coronary Perfusion
3. Transient Abnormalities in Contractility
What are the options available for the management of stable angina?
Medical Treatment, Percutaneous Transluminal Coronary Angioplasty, and Coronary Bypass Surgery
What are the indications for surgery in patients with stable angina pectoris?
Left Main Artery Stenosis, Left Main Equivalent (LAD), and Triple Vessel Disease (LAD, Circumflex, and RCA)
Discuss success in Coronary Bypass and PCTA Surgery:
It has absolute survival benefits over medical therapy in patients with 3 vessel disease.
Percutaneous Transluminal Angioplasty achieved survival advantage over medical therapy in patients with 2 vessel disease.
Ventricular Impairement and Diabetes strongly favor surgery
What is the mechanism of unstable angina?
A plaque with a fibrous cap ruptures. The blood clot forms around the rupture and blocks the artery.
What are the symptoms of unstable angina?
Decreased Exercise tolerance, nocturnal pain, and pain at rest
What are the ways in which a Factor or Stresser affects the diagnosed medical condition?
It influenced the course of the illness by its time relationship.
The factor interferes with treatment.
The factor is an additional health risk
The stress response precipitates or exacerbates the symptoms of the medical condition.
Discuss pathological conditions that appear to be cardiac conditions:
1. Hypochondriasis (look for 6 months of symptoms)
2. Somatization Disorder- multiple, clinically significant complaints about pain (chest pain)
3. Dysthymic Illness- depression-like (heart sick for a long time)
4. Malingering- "get me meds, its the only help"
Stressors can be events, situations, experiences, memories, behaviors, beliefs or personality traits that can be conscious or unconscious. The severity is rated by the Holmes and Rahe rating scale.
What are the factors that work in association with the stressor to produce a true physical illness?
Personality Traits and Defenses
Physical State of Health
Mitral Valve prolapse has a close relationship with this psychological disorder:
Anxiety- Panic Attacks. Generalized Anxiety Disorder affects the autonomic nervous systems and produces cardiac signs and symptoms of palpitations, tachycardia, and chest pain.
Anxiety can also cause Paroxysmal Atrial Tachycardia.
What are the major and common maladaptive behaviors that affect cardiac function?
Obesity, Smoking, Drug Abuse, Alcohol Abuse, IV Drugs
Relate the endocrine system and the heart regarding stress:
Stress causes a sustained rise in Cortisol. High Cortisol is related to high BP, obesity and low HDL.
Discuss the relationship between Cortisol and Acute Grief:
Persons who are experiencing acute grief from loss of a close family member would have a sharp rise of cortisol levels and an abnormal dexamethasone suppression test.
This will return to normal at the end of 2 months when the acute grief period ends. Bereavement can go up to two years however.
Briefly discuss the relationship between stress and the immune system:
Psycho-Neuro-Immunology aka PNI. This identifies changes that occur in the T helper and suppressor cells as well as changes in the NK cells that occur during stress
Discuss "Type A" personality behaviors:
Impatience, Intolerance, Anger, Hostility, achievement oriented, and very competitive.
What is the blood chemistry associated with a Type A personality?
increased low density lip-protein, high blood cholesterol, triglycerides, 17-hydroxycorticosteroids, high norepi.
What malignancy is associated with Type D personalities?
Myocardial infarctions often with poor recovery
What are Type D traits?
Depression, emotional distress with chronic suppression, negative and pessimistic outlook.
What malignancy is associated with Emotional Labile (uncontrollable emotions) patients?
Cardiac Arrythmias. Often with dangerous ventricular tachycardia and ventricular fibrillation.
What is the common biochemical findings in the blood of someone who is Emotionally Labile?
Increased FFA and catecholamines
Explain Chest Pain due to Stress vs Angina
It can simulate an angina episode. Symptoms in stress related chest pain occur at rest unlike stable angina which occurs during exertion.
Pain may also occur in Variant Angina or Unstable Angina or Coronary Artery Spasms related to cocain use or cigarettes
What are the cardiac risk factors that can be changed?
High BP, High Serum Cholesterol, low HDL, smoking, obesity, drug use, stress
What are the protective factors in cardiac disease?
HDL, Exercise, Estrogen, moderate alcohol intake, stress management
Outline what mourning is:
Mourning is a hue change in Role.
It is Adaptation, skill building and is a slow process because they are rebuilding their life.
It is NOT an illness but an abnormal process already present can be exacerbated by mourning.
What are the 5 factors that need to be present for successful mourning?
1. Nurturing social support
2. Balanced Diet
3. Adequate Fluids
4. Range of Motion Exercise
5. Regular Rest Ritual
What did the Interheart Study find regarding coronary heart disease?
Nine factors all related to diet and lifestyle accounted for more than 90% of coronary heart disease risk. CHD is the number 1 cause of premature death.
What did the New England Jounral of Medicine publish regarding angioplasties and stents?
They don't prolong life or prevent heart attacks, but almost 80% of people eligible for the operations were able to safely avoid the surgery by making comprehensive lifestyle changes. In this regard, there was a $30k savings per person in the first year.
What are the dying patients' needs?
Dignity, Self-Esteem, Help in what they cannot do for themselves.