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
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?
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)
-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?
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?
-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
-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
-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
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
-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
leads of anterior aspect of the heart
lab tests for suspected ACS?
-cardiac markers -CBC -CRP -BMP -Coags
-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
-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...