CAD
Pathologic process affecting the coronary artery disease usually due to ____________
Atherosclerosis (hardening and narrowing of the coronary arteries)
CAD
Risk factors
DM(worst risk factor), Smoking(modifiable)
Hyperlipidemia, hTN, men, >45 men; women >55,
family history of CAD
Angina Pectoris
Pathophysiology: Inadequate tissue perfusion due to imbalance b/w increased ________ and decreased _______ _____ ______
increased demand; decreased coronary artery blood supply
Angina Pectoris
when do symptoms typically occur?
70% occlusion
Angina Pectoris
Clinical Symptoms
Chest pain is Classic
---substernal, poorly localized, exertion, short in duration (<30minutes)
RELIEVED WITH REST OR NITROGLYCERIN
Angina Pectoris
associated symptoms
dyspnea, n/v, diaphoresis, numbs fatigue
Angina Pectoris
Angina equivalent chest pain
instead of chest pain, patients develop dyspnea, epigastric or shoulder pain
especially seen in women, elderly, diabetics and obese patients
Angina Pectoris
what is the initially test of choice
ECG
Angina Pectoris
what will the ECG show
ST depression classic finding
T wave inversion
poor R wave progression
*
The resting ECG is normal in 50% of cases
*
Angina Pectoris
what is the most important noninvasive testing
Stress testing
Angina Pectoris
what is the definitive Dx test
coronary angiography
Angina pectoris
management (Outpatient)
Daily aspirin + Beta blocker, sublingual nitroglycerin(PRN), and daily statin
Angina Pectoris
What is the definitive Dx
Revascularization
Angina Pectoris
Revascularization: percutaneous transluminal coronary artery angioplasty
1 or 2 vessel disease in nonDM not involving the left main coronary artery with normal or near normal ejection fraction
Angina Pectoris
Revascularization: Coronary artery bypass graft
left main coronary artery stenosis, 3 vessel disease (2 vessel in Dm
or decreased left ventricular ejection fraction <40%
Angina Pectoris
Class I
Angina only with unusually strenuous activity
no limitations of activity
Angina Pectoris
Clas II
Angina with more prolonged or rigorous activity
slight limitation of physical activity
Angina Pectoris
Class III
angina with usual daily activity
marked limitation of physical activity
Angina Pectoris
Class IV
angina at rest
What is the most useful noninvasive test used to diagnose CAD
Stress testing
Stress ECG
When is it indicated?
useful only if baseline ECG is normal
Stress test ECG
What are positive findings
ECG changed (ST depression, T wave inversions, poor R wave progression
Stress ECG
What are limitations?
Does NOT locate the area of ischemia
Stress Testing: Myocardial perfusion imaging
what dyes does it use for imaging?
thallium or technetium for imaging
Stress Testing: Myocardial perfusion imaging
when is this indicated?
when the ECG baseline is abnormal
gives information regarding the location and extent of ischemia
Stress Testing: Myocardial perfusion imaging
can be performed either with exercise or pharmacologic agent if the patient cannot exercise vasodilators. name the vasodilators
adenosine or dipdyridamole
Stress Testing: Myocardial perfusion imaging
contraindication
contraindication to positive inotropes: severe LV outflow obstruction
(aortic stenosis)
ventricular arrhythmias
recent MI
What is the definitive Dx/Gold standard for Dx CAD
coronary angiography
Acute coronary syndrome
Symptoms of acute MI secondary to _________ &_________
acute plaque rupture and varying degrees of coronary artery thrombosis (Occlusion)
acute coronary syndrome (ACS)
History
angina that is new in onset, crescendo or at rest (usually >30min). >90% occlusion can cause symptoms at rest
Acute coronary syndrome
UA & Nstemi--> Coronary thrombosis
subtotal occlusion
Acute coronary syndrome
STEMI--> Coronary thrombosis
total occlusion
Acute coronary syndrome
ECG for UA/NSTEMI
ST depression &/or T wave inversion
Acute coronary syndrome
ECG for STEMI
ST ELEVATION
Acute coronary syndrome
Cardiac Enzymes present or not present for UA
NOT present
Acute coronary syndrome
Cardiac enzymes present or not present for NSTEMI & STEMI
PRESENT (cell death seen in both NSTEM and STEMI
Acute coronary syndrome
Etiologies
Atherosdclerosis (MCC of MI)
Coronary artery vasospasm
Acute coronary syndrome
Etiologies: Atherosclerosis cause
plaque ruptures--> acute coronary artery thrombosis with platelet adhesion/activation/aggregation along with fibrin formation
Acute coronary syndrome
Etiologies: Coronary artery vasospasm
cocaine-induced
varient (prinzmetal) angina
Acute coronary syndrome:
Clinical manifestations
chest pain: NOT relieved with rest or nitroglycerin, pain at rest >30minutes (may radiate)
Acute coronary syndrome
Clinical manifestation sympathetic stimulation
anxiety, diaphoresis, tachycardia, palpitations N/V dizziness
Acute coronary syndrome
Silent MI RF
Women
elderly
DM
Obese
Acute coronary syndrome
Silent MI Symptoms
abdominal pain, jaw pain, dyspnea without chest pain
Acute coronary syndrome
Physical examination
may be normal
Acute coronary syndrome
PE inferior wall MI
may be associated with Bradycardia or heart block
may have S4
Acute coronary syndrome
Triad of right ventricular infarction
increased JVP+clear lungs+ positive Kussmaul sign
Acute coronary syndrome
what is the time interval for cardiac markers and which one is commonly ordered?
3 send 8hours apart
CK-MB & troponin most commonly ordered
Acute coronary syndrome
what is the time period for CK/CK-MB
appears:4-6hours
peaks:12-24hrs
returns to baseline:3-4days
What is the AMI protocol?
ECG within 10minutes
door to thrombolytics w/in 30minutes
door to PCI within 90minutes (+/- 30minutes)
Management of Acute coronary syndrome
MONA Regimen
Morphine (if no pain relief with nitrates)
oxygen
nitrates
aspirin
Management of Acute coronary syndrome
MONA for STEMI
BB
NTG
ASA
Heparin
ACEI
reprofusion (Most important)
Management of Acute coronary syndrome
MONA for UA or NSTEMI
BB
NTG
aspirin
heparin
*
NO emergent reperfusion
*
Management of Acute coronary syndrome
cocaine-induced MI
ASA
NTG
heparin
anzyloytics
*
AVOID BB because of vasospasm
*
Anterior and Lateral Wall MI
ECG for Anterior wall MI
ST elevations in lead V1-V4 with reciprocal changes (ST depression) in the inferior leads (II,III,aVF)
Anterior and Lateral Wall MI
ECG for lateral wall MI
ST elevation in leads I,aVL, V5,V6 with reciprocal changes (ST depressions) in the inferior leads (II,III, aVF)
Anterior and Lateral Wall MI
Management initially
aspirin(chewed)
nitroglycerine
O2 (If hypoxic)
Morphine(if nitro fails to relieve the pain
Anterior and Lateral Wall MI
adjunct therapy
heparin
BB (if no CI)
clopidogrel
Anterior and Lateral Wall MI
Reperfusion: percutaneous coronary intervention (PCI) ideally within ________ of ER presentation of PCI-capable hospital and within ________ of chest pain onset
90 minutes
12 hours
anterior and lateral wall MI
Reperfusion: thrombolytics within _____ minutes of ER presentation is an alternative to catheterization if PCi is not possible
30
Inferior or Posterior wall MI
complete occlusion to what artery?
RCA
Inferior or Posterior wall MI
what will the physical exam show
bradycardia or heart blocks (RCA supplies the AV node)
+/- S4
Inferior or Posterior wall MI
triad of right ventricular infarction
increased JVP + clear lungs + kussmaul sign
Inferior or Posterior wall MI
Dx on ECG (inferior)
ST elevation in inferior leads (II,III,aVF) with reciprocal changes (ST depressions) in leads I & aVL
Inferior or Posterior wall MI
Dx on ECG (Posterior)
St depressions in V1-V4
Inferior or Posterior wall MI
are cardiac enzymes present>
yes
Inferior or Posterior wall MI
initial management
anithrombotic therapy
(aspirin, heparin)
IV fluids
O2
clopidogrel
Inferior or Posterior wall MI
what must you avoid in treatment with inferior and posterior wall MI
Nitroglycerin and morphine
Inferior or Posterior wall MI
reperfusion: what is preferred and in what time frame?
catheterization lab preferred (ideally within 90minutes of Er presentation an within 12 hours of chest pain onset)
Inferior or Posterior wall MI
if you can not do the cathetization what is your next option>
thrombolytics within 30minutes
complications of myocardial infarction
arrhythmia (Ventricular fibrillation), ventricular aneurysm/rupture
Dressler syndrome: post-MI pericarditis+Fever+pulmonary infiltrates