Cardiac

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What are 6 differential dx for angina?
1. pericarditis
2. esophageal spasm
3. chest wall pain
4. aortic dissection
5. GI pain
6. pleural/pulmonary
True or false...women with ischemia present with atypical symptoms of chest pain
true, up to 65% of women
Chest pain classifications (3)
1. typical angina- chest discomfort with a characteristic quality and duration that is a. provoked by exertion or emotional stress and b. relieved by rest or nitroglycerin

2. atypical angina- meets two of the above characteristics

3. noncardiac chest pain- meets 1 or non of the typical angina characteristics
Risk factors for CHD
abnormal lipid levels, smoking, htn, diabetes, genetics, gender, abdominal obesity, stress, low consumption of fruits and begs, etch, lack of PA
CHD defined
mismatch of myocardial supply and demand
management of stable angina
smoking cessation, weight reduction, decrease CHOL, ASA, beta blockers, ACE I
stable angina defined and characteristics
chest pain due to fixed coronary stenosis with compromised blood flow and progressive plaque growth, discomfort and pressure, not pain, stable pain last 5-15 minutes, provoked by exertion or stress, relieved by nitro or rest
2 most common reasons for visit to ED for people over 15 years old?
chest and abdominal pain
esopheogeal spasm is r/t meals and swallowing? true or false
true
LDL goal for normal healthy adult? LDL goal for RF or HD patients?
LDL less than 100, less than 70 for HD or RF pts
when do the majority of deaths occur for patients with CHD?
within 96 hours
T/F, CHD is the most common cause of morbidity and mortality in the US, 1/5 deaths?
true
Angina- defined
ischemic chest pain without lab and/or ecg findings consistent with acute MI
EKG findings that have a worsening prognosis
1. prior MI (q waves)
2. R wave in V1 (posterior infarction)
3. St-T wave inversion- esp in lease v1-v3
4. left BBB or bifasicular block
5. tachy or PVCS
6. LV hypertrophy
7. 2nd or 3rd degree AV block
exertional/chronic stable angina
most common type, periods or pressure or discomfort, relieved by sublingual nitro, lasts 1-3 minutes, constants, females more than men, ecg T wave inversion = ischemia
silent ischemia occurs in what percentage of patients?
up to 70%
Unstable Angina classifications
1. new onset angina (onset less than 2 months)
2. severe or accelerating angina without rest pain (crescendo pattern), requires work up with treadmill test
3. pain on awakening (immediate evaluation)
4. subacute unstable angina (rest angina within past month but not preceding 48 hrs)
5. acute unstable angina (rest angina within 48 hours)
Prinzmetal's angina- pathology, characteristics, findings, causes
-variant of angina- caused by coronary artery spasm
- history of spontaneous or unprovoked episodes of typical angina- occurs at various times, includes resting angina that intensifies and increases in duration and frequency, discomfort occurs at rest, while smoking, at night, in recumbent position
T/F Prinzmetal's angina is not accompanied by palpitations or SOB?
false!
ECG changes with Prinzmetal's angina?
-ST elevation or depression while patient experiencing pain, returns to baseline when pain is gone
-vasospasms usually involves right coronary artery- ecg, ST changes in leads II, III, and aVF
vasospasms in prinzmetal's angina can cause (3)
1. heart block
2. v tach
3. sudden death
treatment for prinzmetal's angina in women
seen in women more than men, use CCB
types of stress tests?
1. standard exercise- TM, arm ergometer, bicycle- not commonly done
2. EST with scintiagraphy- thallium sestimibi (with nuclear imaging)
3. pharmologic stress scintigraphy- dobutamine or adenosine (for pts who can't walk)
4. echo with other stress tests
sensitivity and specificity of EST?
-very accurate and reliable
-controlled increased heart 02 demand, reliable with fixed stenosis and ekg changes
-difficult to detect low grade (less than 50% stenosis)
-difficult to interpret with collateral circulation and fixed stenosis
lab studies for pre-evaluation for EST
-chemistry
-hematologic profile
- resting EKG
indications for EST?
-classic anginal symptoms
-SOB or dyspnea or exertion
-pts with CAD or post CABG when stable
-post MI 6 week changes
-asymptomatic healthy people with high risk occupations (fire fighters, pilots, mass transit operators)
-women over 50, men over 40 beginning to exercise
-2 or more RF
-valvular dx
CI for EST?
-acute MI
-unable angina
-cardiac inflammations
-severe CHF
-uncontrolled arrythmias
-symptomatic arrythmias
-high grade heart block
-aortic stenosis
-severe HTN
-acute medical illness
-electrolyte imbalance
-active PE or DVT
- extreme obesity
-mental or physical disabilities
pre-test instructions for EST?
-may or may not take BB
-hold insulin
-caution with TCA and proarrhythmic
patients with __ or ___ may have excessive tachycardia during EST?
MVP and WPW
EST + for ischemia?
-exercise induced hypotn (rop of more than 10 SBP)
-exercise induced angina
-ST changes, P or T wave changes
-conduction abnormalities during exercise or recovery
-2-3 mm ST depression
-S3 or S4 or heart murmer
the presence of s3, s4, or heart murmur during exercise stress test may indicated...
cardiac muscle dysfunction
3 components of ACS (acute coronary syndrome)
-STEMI
-NSTEMI
-unstable angina
____ % of women and ___ % of men with ACS have classic angina type pain?
40% women and 70% men
which populations have atypical presentations of ACS?
-women
-elderly
-DM
characteristics or findings of AMI or unstable angina?
-chest tightness
-heaviness
-substernal pain (relieved by nitro)
-radiating pain
-diaphoresis
DX findings of AMI?
-ST segment elevation greater than 1 mm in 2 leads, t wave inversion, Q wave, loss of R wave, conduction deficits
DX findings of unable angina?
- st elevation or depression
signs/symptoms of chest pain discomfort in unstable angina or AMI?
-midline, substernal chest pressure
-back, shoulder, neck, and jaw pain with radiation
-burning sensation in chest
-breathlessness, tightness
-unexplained indigestion, belching, epigastric pain
-dyspnea, n/v
DD for AMI?
-heartburn
-costochondral pain
-pericarditits
-pleuritic chest pain
-chronic cholcystitis
-spontanous pneuo
-cervical/thoracic spine dx
stable plaque
-differ in composition, consistency, vulnerability, and tendency to generate thrombus
-can cause narrowing of arterial lumen
-70% or greater causes angina in men
-complete obstruction= infarction
-often develops collaterals overtime
unstable plaque
-vulnerable plaque- fibrous cap ruptures, theories of plaque rupture
-coagulation cascase is initiated resulting in thrombosis and further PLT adhesion
-complete occlusion may result in STEMI or sudden death
ventricular walls (3)
1. epicardium- outer layer
2. myocardium- middle
3. endocardium- inner layer
2 layers of the myocardium
-inner most half- subendocardial area
-outer most half- subepicardial
which layer of the myocardium has the greatest risk for ischemia?
-subendocardium- has the highest demand for o2 and is fed by the distal branches of the coronary arteries
Ischemia defined...
increased 02 demand and decreased 02 supply
ischemia effects and affects?
-affects cardiac cells responsible for contractions and conduction of electrical impulses
-results in changes in depolarization and depolarization ST segment and T wave changes
-decreases pump function
causes of injured cells due to ischemia?
do not depolarize completely remaining more electrically + then the uninjured areas surrounding them- ST segment elevation in the leads facing affected area
Myocardial injury and ST elevation
-acute process from total occlusion of coronary arteries- leads to transmural damage
-needs immediate tx to restore BF and preserve heart
ST elevation in AMI is called?
-supply related ischemia- occurs in minutes
unstable angina definition, symptoms, and ED presentation
-painful
-symptoms occurs at rests or with minimal exertion
-may last more than 20 minutes
-may be severe or new onset (in last 4-6 weeks)
-symptoms may be more severe, prolonged, frequent
-ED presentation may be similar to AMI
AMI defined?
-necrosis of heart tissue
-tissue death occurs as a wave starting at endocardium and spreads to epicardium
-more time= more necrosis
AMI clear DX?
-rise and gradual fall in troponin or rapid rise in CK-MB with at least one of the following
1. ischemic symptoms
2. development of Q wave
3. ECG changes- ST elevation or depression
AMI clinical presentation?
-75% chest discomfort
-n, SOB, weakness, dizziness, sweating, anxiety, lightheadedness, syncope, palpitations, fatigue
-20% population with anginal equivalent symptoms (weakness, fatigue, abdominal discomfort)- seen in women, DM, elderly
leads of lateral aspect of the heart
I, aVL, V5, V6
leads of inferior aspect of heart
II, II, aVF,
leads of septum aspect of the heart
V1, V2
leads of anterior aspect of the heart
V3, V4
lab tests for suspected ACS?
-cardiac markers
-CBC
-CRP
-BMP
-Coags
CK-MB
-normal reading does not exclude possible AMI
-elevated 4-6 hours post AMI
-24 hours returns to baseline at 3 days
-cardiac specific
-q6-8 hours for first 28 hours
Troponin
-elevated 4-8 hours post AMI
-TNI- more cardiac specific, peaks in 24 hours, returns to normal in 7-10 days,
TNT- rapid testing available, may be elevated for RF
-check 2 x 6-8 hours apart
Troponin elevated for a variety of different reasons including...
tachyarrhythmias, HTN, myocarditis, myocardial contusion, CHF, cardiac surgery, RF
BNP markers
-marker of CHF
-predictive of adverse cardiac events in patients with ACS
CRP markers
-directly involved in coronary plaque
-useful indicators in patients with ACS
-elevated CRP predictors of cardiac death, AMI, CHF
-biomarker of CAD
MPO markers
-leukocyte enzyme, linked to lipid production, plaque instability, lipid soft plaque creation, vasoconstriction from NO
ischemia modified albumin
-produced when circulating serum albumin contacts ischemic heart tissues
indications for cardiac catheterizations...
-stable angina with abnormal ST
-unable angina
-abnormal imaging/studies
-recurrent angina post interventions
-STEMI
-NSTEMI
-pre-op evaluation
treatment options during cardiac catheterizations?
-PCI- stents
-medical managment
-CABG
-nothing
benefits of PCI/stents?
-less invasive
-shorter hospital stay
-quicker recovery
-lower cost
after a stent placement, all patients must be placed on which medication?
ASA or plavix
indications for PCI?
-persistent ischemia despite medical tx
-not a CABG candidate
-single or multi-vessel dx
-native or graft dx
-lesion characteristics
-partial or total occlusions
PCI interventional procedures?
-stents
-DES- drug eluding stents
-PTCA- percuataneous transluminal coronary angiplasty
-rotoblader- pulls out plaque
-artherectomy
-brachytherapy- prevents restenosis from intimal hyperplasia
brachytheraphy PCI benefits
delivers ionized radiations to the arterial wall reducing hyperplasia and restenosis
vascular closure devices post catheterization?
-goal to achieve hemostasis
-improve patient comfort
-early ambulation
-collagen or pro-coagulant pads
groin complications post cath include?
-bleeding
-pseudoaneurysm
-retroperitoneal bleeding
-AV fistula
-fistulas
Nitrates for MI management and treatment
-short acting sublinginal
-dilators that decrease heart 02 demand
-q5 minutes x3
-long acting- isosorbide, imdur
beta blockers for MI management and treatment
-reduce heart 02 requirement by decreased HR, contractibility, and BP
-slows AV conduction- prevent arrythmias
CCB for MI management and treatment
-induce vasodilation-reducing 02 requirements
-rate lowering have role in stable angina (verapamil and dilitzem)
ACE I for MI management and treatment
-prevent plaque rupture, esp in pts with CHF
-systolic dysfxn- prevent remodeling
-LVD dilatation