CM1 E3 Lz14 Angina

stable angina

pain episodes are brought on by a predictable level of exertion or stress

pain is relieved by nitroglycerin or resting for several minutes

unstable angina

pain occurs at rest or with a significant change in previous pattern

chronic stable angina pectoris

chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient

chronic stable angina pectoris etiology

atherosclerotic heart disease

or

coronary vasospasm

other: congenital anomalies, emboli, arteritis, or dissection

stable angina prefered positioning

pt may prefer to remain upright rather than lie down as increase preload during recumbency increases myocardial work

stable angina pain description

described as tightness, squeezing, burning, pressing, choking, aching, bursting, gas, indigestion, or poorly characterized discomfort

rarely sharply localized

stable angina pain location and radation

sub sternal or left of mid sternum

radiates to left shoulder and upper arm

Levine sign

Clenched fist held over the chest to describe ischemic chest pain

Nitroglycerin

vasodilator that increases blood flow

decreases arterial and venous tone, preload and afterload, and lowers the oxygen demand of the heart

nitroglycerin diagnosing angina

if sublingual nitroglycerin promptly and invariable shortens an attack then angina dx is supported

angina BP

significant elevation in systolic and diastolic bp

Bezold-Jarsich reflex

may cause hypotension due to severe ischemia

angina clinical signs

May have gallop rhythm and apical systolic murmur due to transient mitral regurgitation from papillary muscle dysfunction

Supraventricular or ventricular arrhythmia may be present

resting angina ECG

usually normal

anginal episode ECG

horizontal or down sloping ST-segment depression that reverses after the ischemia disappears

May have T wave flattening or inversion

angina pretest probability

Use history, PE findings, lab, and ECG findings to determine the probability for CAD

Also include age and sex and clinical symptoms

low to intermediate angina pretest probability

noninvasive stress testing

high angina pretest probability

cardiac cath

exercise ECG

Measures response to an increasing workload

uses Bruce protocol

Bruce protocol

increases speed and elevation every 3 minutes during exercise ECG until limited by symptoms

exercise ECG contraindications

pain at minimal activity (NYHA 3 and 4)

symptomatic aortic stenosis

exercise ECG positive test

1 mm horizontal or downsloping ST-segment depression measured 80 msec after the J point

may be false positives

2mm depression is severe disease

myocardial stress imaging includes....

Includes scintigraphy, echocardiography, or MRI

myocardial stress imaging indications

● Resting ECG makes an exercise ECG difficult to interpret

● Confirmation of exercise ECG results when contrary to clinical impression

● To localize region of ischemia

● To distinguish ischemic from infarcted myocardium

● To assess completeness of revascularization after intervention

● Prognostic indicator in patients with known CAD

other cardiac imaging

PET scan, CT scan, and cardiac MRI

PET scan

used to determine stunned myocardium that can be reactivated from dead scar tissue

Coronary angiography

Definitive test for CAD

invasive and higher cost

only recommended if high pretest probability

Done in appropriate circumstances if percutaneous transluminal coronary angioplasty or bypass surgery is a consideration

coronary angiography results

narrowing of 50% of lumen is significant

>70% is symptomatic

>90% will show sx at rest

stable angina tx

sublingual nitroglycerin

if pt does not respond then acute MI may be present

stable angina prevention

nitroglycerin before activity

long acting nitrates

beta blockers

stable angina first line

beta blockers

ranolazine

prolongs exercise duration and time to chronic angina

does not improve overall outcome

stable angina CCB tx

don't use first line

may increase ischemia and mortality

long acting nitrates

Used to PREVENT anginal episodes

end in "nitrate"

B blockers affect on CAD

only antianginal agents that have been shown to prolong lif in patients with CAD post MI

chronic angina tx progression

1. Beta blockers

2. long-acting nitrate

3. CCBs or ranolazine

AND

ASA 81mg daily

platelet inhibiting agents

ASA 81 mg

Clopidogrel, ticagrelor, Rivaroxaban, DAPT

DAPT (dual antiplatelet therapy)

recomended in pt post MI and post stent

angina blood glucose control

avoid tight control with HgA1c

revascularization indications

Symptoms despite therapy

Coronary artery stenosis >50% or EF

percutaneous coronary intervention

ballon angioplasty and coronary stenting can open stenotic coronary arteries

DAPT for one year after stent

drug-eluting stents

Stents releasing medication to prevent restenosis.

CABG

coronary artery bypass graft "open heart surgery"

uses one or both internal mammary arteries for long term patency and flow

PCI

percutaneous coronary intervention

used in patients with symptomatic single or double vessel disease

Duke Treadmill Score

based on Bruce protocol exercise treadmill test and provides an estimate of risk of death at 1 year

Unstable angina factors

1 of 3

1. occurs with minimal exertion and is prolonged

2. severe and of new onset

3. recent acceleration

unstable angina workup

should be worked up as MI and admitted for chest pain observation

coronary vasospasm

spasms of the large coronary arteries with resulting in decreased coronary blood flow

can result in acute MI

coronary vasospasm etiology

exposure to cold, emotional distress, or vasoconstricing medications

COCAINE

Prinzmetal angina

ischemia due to vasoconstriction without usual precipitating factors

Prinzmetal angina ECG

shows ST segment Elevation rather than depression

Prinzmetal angina RF

women under the age of 50

Prinzmetal angina tiime of day

occurs in the early morning and awaken the patient from sleep

Prinzmetal angina dx

vasoconstrictor challenge

risky

Prinzmetal angina imaging

coronary arteriography is ST segment elevation is present

Prinzmetal angina tx

medical therapy or revascularization

episodic tx with nitrates

prophylactic tx with CCBs and nitrates

Prinzmetal angina and Beta blockers

can exacerbate coronary vasospasm