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533 > Final: CAD/chest pain/cardiac diagnostics > Flashcards

Final: CAD/chest pain/cardiac diagnostics Flashcards

1
Q

What are the most common causes of chest pain in adolescents? what sx’s are those?

A
  • 35% of chest pain is costochondritis (musculoskeletal)
    • Insidious onset
    • Persists for long period of time
    • Positional component
    • Began after repetitive use of an upper extremity
  • 19% GI souce
  • 16% idiopathic
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2
Q

acute coronary syndrome (ACS) sx’s

A

GET MORE HISTORY! then send to cardiac care facility for management

  • since chest pain affects every organ, want MORE history and not imaging
  • Worsening in the frequency, intensity, duration, and timing (ie, nocturnal pain, rest pain) of prior anginal or anginal equivalent symptoms
  • New-onset shortness of breath, nausea, sweating, extreme fatigue in a patient with a known history of CVD
  • Onset of typical anginal symptoms in a patient without a history of cardiovascular disease
  • New findings on physical exam of murmur (or worsening of a previously noted murmur), hypotension, diaphoresis, rales or pulmonary edema
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3
Q

want to rule out psychiatric concerns bc

A

Domestic violence is one such cause of chest pain similar to myocardial infarction (MI)

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4
Q

ECG changes for acute coronary syndrome

A
  • ST elevation (STEMI >1mm) / depression
  • pathologic Q waves
  • T waves
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5
Q

after completing a thorough hx/ E for chest pain…

A

Evaluate need for emergent care: if think ACS, chew an aspirin & go to ED.

ED also if seriously ill, such as pneumothorax, pulmonary embolism, pneumonia, aortic dissection, etc.

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6
Q

acute pericarditis diagnosis

A

triad

  1. pleuritic chest pain (stab/burn pain when breathing)
  2. pericardial friction rub (heard leaning forward at end expiration)
  3. diffuse ST wave elevation
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7
Q

what clinical features increase likelihood of it being an MI in patients?

A
  • acute chest pain radiates to both arms
  • 3rd heart sound
  • hypotension
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8
Q

pain that worsens with inhalation

A

pleuritic chest pain

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9
Q

diagnostics for heart failure

A
  • Echo
  • chest xray
  • ECG (structural heart disease, conduction disease)
    • if normal = NOT HF
  • hematocrit - anemia
  • thyroid function - exclude thyroid dz
  • fasting lipid panel and fasting glucose (and A1c) - screen for hyperlipidemia, metabolic syndrome, DM
  • UA, BMP
  • brain natriuretic peptide (BNP) - if normal = HF unlikely
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10
Q

standard diagnostic for coronary artery disease

A

coronary angiography

for any obstructive lesion producing sx’s or those at risk of ACS

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11
Q

when is a coronary angiography indicated

A

new systolic heart failure and angina

pt w/o angina with no previous evaluation of coronary anatomy d/t high prevalence of CAD in older adults

can exclude coronary anomalies in younger pts

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12
Q

3 most important factors that determine Oxygen demand is determined are:

A
  • Heart rate
  • systemic BP (peripheral vascular resistance)
  • Left ventricular wall tension (anything that increases heart workload)
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13
Q

stable angina symptoms

A
  • chest pain/discomfort from exertion, stress, large meals, cold weather
  • relieved in 1-3 mins by rest or by 1 nitroglycerin
    • < 5 mins
      • if >20 mins pain = ACS
  • NOT localized pain
    • Levine sign - make fist over sternal area
  • substernal tightness / pressure
  • more predictable
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14
Q

differentials to run out for chest pain

A
  • r/o non-emergent causes
    • GI
    • Pulmonary
    • Valvular inflammatory
    • Integ
    • Psychological disturbances
      • Issues at home
      • Domestic violence
  • r/o life-threatening events
    • Aortic dissection
    • MI
    • PE
    • Spontaneous pneumothorax
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15
Q

unstable anginal sx’s

A
  • At rest or minimal exertion chest pain, nausea, light headed, SOB, epigastric pain, diaphoretic skin
  • not localized, not stabbing
  • Persistent pain
  • not relieved with rest or nitroglycerin
  • > 10 mins
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16
Q

atypical symptoms of angina and more common in who?

A
  • dyspnea, indigestion, nausea, numbness in the upper extremities, jaw pain, pleuritic pain, and fatigue (rather than actual chest pressure)
  • more common in diabetics, women, elderly
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17
Q

Gold standard/first line to diagnose unstable angina:

A
  • Stress test/exercise tolerance test within 72 hrs of angina if EKG inconclusive
  • want to reproduce the stress in the heart /dyspnea on exertion under controlled situations WHEN THEY ARE NOT HAVING CHEST PAINS
  • less effective in women bc women have non obstructive or single vessel disease
  • on ECG - looking for downscoping or horizontal ST
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19
Q

Contraindications to stress test

A
  • DO NOT DO IF ACTIVE MI sx’s, EKG changes, Cardiac in nature
  • active chest discomfort
  • Mobility issues
  • Amputees
  • Schedule with hip replacement
  • Dementia

only put asymptomatic patients

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20
Q

Duke treadmill scores

A
  • stress test point system to predict 5-year mortality using Bruce protocol
  • ST-segment deviation (depression or elevation), and the presence and severity of angina during the exercise
  • score = exercise duration (minutes) - 5*(ST deviation/mm) - 4*(angina index)
  • low risk
    • score > 5 = 5 year survival of 97%
  • intermediate risk
    • score between 4 and -10 = 90%
  • high risk
    • score < -11 = 65%
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21
Q

secondary prevention for coronary artery disease/vascular disease checklist:

A
  • complete smoking cessation
  • BP < 140/90, < 130/80 if HF or renal insuff
  • eval before statin, fasting lipid panel, ALT/CK
  • if < 75: high intensity Atrovastatin 80mg/rosuvastatin 40mg
  • if > 75: moderate statin
  • reduce sat fat < 7%
  • triglycerides < 200
  • 30 min exercise x7 days
  • BMI 18.5-24.9
  • hemoglobin A1c < 7%
  • aspirin 81mg QD (clopidgrel or warfarin if contraindicated)
  • BB
  • metformin
  • ACE inhibitor (if have CKD or diabetes)
  • influenza vaccine
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23
Q

labs to check for stable angina

A
  • Lipid profile
  • Hemoglobin A1C
  • CBC
    • Anemia (limited myocardial oxygen supply)
    • Hemoglbin < 7, can have ST segment/depression
    • Polycythemia
    • Thrombocytopenia
    • Elevated platelets
    • Anything that increases viscosity of blood = impedes flow
  • Serum creatinine
  • B-type natriuretic peptide (BNP) (evidence of HF)
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24
Q

coronary artery disease management

A
  • BB for ALL pt’s with MI, ACS, or Left ventricular dysfunction history
    • or CCB
      • no BB if COPD
      • can use Ranolazine (Ranexa) instead if bradycardia & can’t do BB/CCB
  • ACE inhibitors for ALL pts with ejection fraction < 40, HTN, DM, or CKD
  • nitrate PRN
  • aspirin, clopidogrel or warfarin
  • statin
  • flu shot
  • if meds fail: coronary angiography (PCA)
  • f/u q 4-6 months 1st year, then q 4-12 months
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26
Q

evolution of MI on ECG

A
  • minutes: ST elevation
  • hours: R ave, Q wave
  • 1-2 days: T wave inversion, Q wave deeper
  • days: ST normalizes, T wave inverted
  • weeks: ST & T normal, Q wave persists
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29
Q

if have 2 continuous ST segment elevation..

A

get to PCI capable center within 90 minutes for reperfusion

if can’t, give fibrinolytic therapy within 30 minutes

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30
Q

acute STEMI management

A
  • Reperfusion therapy or fibrinolytic therapy
  • Dual antiplatelet therapy
  • Anticoagulation
  • Aspirin, clopidogrel
  • Short term anticoag (heparin) for 2-8 days
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31
Q

Non ST-segment Elevation-ASC management

A
  • Detailed hx, PE
  • 12 lead ECG within 10 minutes of arrival
  • troponin I or T now and 3-6 hrs after sx onset
  • chew aspirin 162-325 mg asap
  • Oxygen if needed
  • daily BB
  • sublingual NTG
  • heparin
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32
Q

what medications worsen heart failure? (heart is unable to meet the metabolic demands of the body)

A
  • NSAIDs/Naproxen
  • CCB - depresses myocardial contractility
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33
Q

angina treatment

A
  • smoking cessation
  • BP < 130/80 (CCB/ACE)
  • statins
  • PA 30 min/day 5-7x/wk
  • BMI 18.5-24.9
  • diabetes: Hgb A1C < 7%
  • metformin for all diabetics with CAD
    • also semaglutide, empaglifozin decrease CVD deaths in DM
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34
Q

if unstable angina, #1 thing to do next?

A

EKG w/in 10 mins! Leads will tell location

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35
Q

what is Thrombolysis in myocardial infarction (TIMI) score?

A
  • risk score for unstable angina/NSTEMI
    • 1 pt for:
      • > 65
      • _>_3 CAD risk factors (fam hx, HTN, HLD, Dm, current smoker)
      • ASA in last 7 days
      • elev cardiac markers (CK-MB or troponin)
      • ST deviation > .5 mm, prior CAD > 50%
  • if score 5 (high): go to PCI center hospital within 90 mins
  • if score 3-4 (intermediate): give ASA/nitrate, f/u in 72 hrs
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36
Q

ACS/MI workup/labs

A
  • EKG w/in 10 mins
  • draw troponin (peaks at 3-4 hrs) 3x, at presentation, 3 hrs, at 6 hrs
  • elevated for a week
  • Chest xray (r/o pneumonia, pneumothorax)
  • CBC (anemia)
  • BMP, fasting glucose, lipids, thyroid, mg
  • consider CRP, BNP
  • echo for wall motion
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37
Q

ACS/MI Treatment

A
  • aspirin 325 chewable table asap
  • NTG tab (unless had phosphodiesterase inhibitor 48 hrs ago)
  • statin w/in 24 hrs of event
  • BB w/in 24 hrs unless CI
  • consider heparin bolus
  • ALS transfer to hospital
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38
Q

unstable angina vs NSTEMI

A
  • unstable angina: persistent ST segment depression > 1 mm for > 48 hrs
    • no Q waves, no R waves
39
Q

STEMI workup

A
  1. EKG (shows persistent ST segment elevation with no LV hypertrophy or LBB with elevated cardiac markers in 2 continuous leads
  • ST elevation > 2mm in males, > 1.5 mm females
  • new onset BBB
  1. Labs (troponin!!!! cardiac specific, CK-MB, myoglobin [earliest marker for cell injury but not cardiac specific)
  2. ECHO
40
Q

Acute coronary syndrome

A

consists of:

  • unstable angina
  • NSTEMI
  • STEMI
41
Q

STEMI treatment:

A
  • aspirin 325mg chewable tablet
  • go to PCI center w/in 90 mins
    • start fibrinolytic therapy w/in 30 mins if transfer takes longer then 2 hrs
    • reperfusion therapy w/in 12 hrs onset
  • post PCI: dual anti-platelet therapy (P2Y12 receptor inhibitor/Plavix and aspirin x 30 months)
  • BB w/in 24 hrs
  • ACE, CCB
  • nitrates
42
Q

Post MI

A
  • future risk of CV events
  • f/u cardiac rehab
  • assess med compliance, SE, sx’s, risk factors, comorbidities
43
Q

non invasive tests/biomarkers for CAD testing

A

C- reactive protein, interleukin -6, monocyte macrophage colony stimulating factor

44
Q

Cardiac testing: C-reactive protein can be used in who for what?

A
  • ASYmptomatic men 50+/women 60+ with LDL < 160 if statin therapy is needed
  • assesses CVD risk
45
Q

Cardiac testing: ankle brachial index (ABI)

A

assess intermediate risk for subclinical CVD

46
Q

cardiac testing: CACS

A

coronary artery calcium scoring

0: normal
10: low
400: high

r/t to plaque burden, high radiation exposure

47
Q

cardiac testing: exercise tolerance test/stress test NOT in who?

A

DON’T DO IN ASYMPTOMATIC PPL WITH NO HX OF REVASCULARIZATION

48
Q

cardiac testing: exercise tolerance test/stress test indication & results?

A
  • detects CAD in pt’s with angina or dyspnea on exertion who are at intermediate risk of ACS
  • first line testing
  • predicts future cardiac events/functional capacity
  • normal ECG response: isoelectric ST segment during exercise and recovery
    • positive ETT if horizontal/downsloping ST segment depression of 1 mm
    • non dx if can’t reach target HR [220 - age], unless there are ST changes before max HR reached
  • OR exercise induced hypotension (SBP falls 20+ any point during exercise)
49
Q

what causes lowered specificity of an exercise tolerance test?

A
  • prior MI
  • BBB
  • conduction abnormality
  • pacer
  • pre excitation syndrome or inability to exercise
50
Q

Exercise TT medication management before ETT

A

if ETT ordered d/t angina, ask cardiologist if should stop BB 1-2 days before test

if ETT is to see current pharm regimen is effective → continue BB

51
Q

contraindications to exercise TT

A

ABSOLUTE: active endocarditis, HF, MI past 2 days, can’t exercise, persistent stable angina, uncontrolled arrhythmias, heart blocks, aortic stenosis

relative CI: Complete heart block, cardiomyopathies, recent stroke/TIA, severe HTN, tachyarrhythmias

52
Q

indications to add nuclear/ultrasound imaging to exercise TT

A
  • Left ventricle hypertrophy with ST segment and T wave abnormalities on resting ECG
  • baseline ST/T wave abnormalities on resting ECG
  • recent MI
  • use of digoxin
  • Wolff-parkinson white syndrome, BBB, vent pacemaker
53
Q

cardiac testing: exercise echocardiography

A

abnormal left ventricular EF or wall motion abnormalities using dobutamine

54
Q

pharmacologic stress test

A
  • for those that can’t exercise/treadmill
  • use coronary vasodilators (dipyridamole (Persantine) and adenosine and inotropic chronotropic (dobutamine) [reversed with aminophylline] to unmask variations in flow NOT ischemia
  • assess effective coronary flow reserve
  • ECG 20% show angina
55
Q

Types of Heart failure

A
  • HF with reduced EF < 40%
    • systolic HF
    • can’t contract/empty = decrease CO
  • HF with preserved EF > 50
    • diastolic HF
    • impaired vent filling/relaxation
  • HF with mid range LVEF 40-49%
    • sx’s both systolic and diastolic HF
56
Q

left side HF vs right sided HF symptoms

A
  • dyspnea and fatigue
  • sx’s SUBLE due to fluid overload in body
  • Left sided HF: fatigue dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough, s3 or s4 heart sound, displaced apical pulse, crackles if pulmonary edema
  • R sided HF (advanced L sided HF): LE edema, fatigue, exercise interlace, JVD, nocturia, ascites, hepatomegaly, nausea, S3 heart sound
57
Q

HF compensations

A
  • higher renin and adolsterone - Na retention = increases CO (give ACE/ARB)
  • adrenergic to boost contractility (give BB)
  • ventricular remodeling = dilation and thinning, worsens HF
58
Q

NY Heart Association Functional Classification (based on Sx severity): Class 1

A

no limitations - asx with activity and rest

59
Q

NY Heart Association Functional Classification (based on Sx severity): Class 2

A
  • slight limitation. comfortable at rest
  • Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath)
  • ex: sx’s occur after climbing 1 flight of stairs but pt does not need to stop
60
Q

NY Heart Association Functional Classification (based on Sx severity): Class 3

A
  • Marked limitation of physical activity.
  • Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea
  • ex: pt can’t climb 1 full flight without stopping/ need break
61
Q

NY Heart Association Functional Classification (based on Sx severity): Class 4

A
  • inability to carry on any physical activity without discomfort and sx at rest
  • ex: pt can’t climb more than 1 step or sx start when grooming
62
Q

NY Heart Association Functional Classification (based on Sx severity): Class 5

A
  • inability to carry on any physical activity without discomfort and sx at rest
  • ex: pt can’t climb more than 1 step or sx start when grooming
63
Q

ACC/AHA heart failure stages: Stage A

A
  • high risk of HF
  • NO SX’s or STRUCTURAL changes
  • ex: pt with HTN, obesity, DM
64
Q

ACC/AHA heart failure stages: Stage B

A
  • STRUCTURAL changes but no sx’s
  • ex: hx of MI with some remodeling, asx valvular heart disease, preheart failure
65
Q

ACC/AHA heart failure stages: Stage C

A
  • structural changes AND symptoms
  • hx of sx’s of HF or current
66
Q

ACC/AHA heart failure stages: Stage D

A
  • ADVANCED structural changes
  • symptoms at REST (despite max medical therapy)
  • refractory HF (recurrent fluid overload, hospitalizations)
67
Q

Framingham criteria for diagnosing Heart Failure

A

Need 2 major OR 1 major + 2 minor:

  • major:
    • acute pulmonary edema
    • cardiomegaly
    • hepatojuglar reflux
    • neck vein distention
    • paroxysmal nocturnal dyspnea/orthopnea
  • minor
    • ankle edema
    • dyspnea on exertion
    • hepatomegaly
    • nocturnal cough
    • pleural effusion
    • tachycardia > 120 HR
68
Q

HF workup

A
  • CBC
  • serum electrolytes
    • Ca, Mg,
  • BUN/Cr
  • glucose
  • lipids
  • TSH, UA
  • BNP
  • N terminal proBNP
69
Q

when is Brain natriuretic peptide (BNP) secreted? useful for? increased/decreased in?

A
  • can rule out HF
  • increased with age, ACS, anemia, COPD, pulmonary HTN
  • lower in obese pt’s
  • if pt on ARNI [Sacubitril/valsartan (Entresto)], draw pro BNP instead
  • BNP > 50 = dx early HF in high risk pts
70
Q

ECHO

A
  • most effective tool in HF assessment
  • assess ventricle thickness, function, EF, valve dz, regurg/stenosis, size, wall motion
71
Q

if pt has HF with reduced EF NEW ONSET

A

send to cardiology!

72
Q

how likely is HF with normal BNP and normal echo?

A

unlikely!

73
Q

always r/o what with new onset of heart failure?

A

ACS!

74
Q

heart failure management

A
  • NO CCB, NSAIDs
  • Na restriction, weight loss, med compliance
  • hospitalization with new onset HF w/ sx/s fluid overload, suspect infarction, pulmonary edema with low O2 sats, unstable pts
  • assess for obstructive sleep apnea
75
Q

HF med management

A

target RAAS system!

  • diuretics (relieve congestion): HCTZ or Loop
    • titrate up if > 5lb gained in 2 days
  • treat OSA, anemia, electrolyte imbalances etc
76
Q

Stage A HF management

A

statin, BP < 130/80, control arrhythmias (BB, amio), manage diabetes

77
Q

Stage B HF management

A
  • BNP screening
  • treat BP w/ ACEI/BB (carvedilol, metoprolol, bisoprolol)
  • vascular repair if needed
  • consider ICD placement if LVEF < 35%
78
Q

Stage C HF management

A

*classify pt as either reduced/systolic HF or preserved/diastolic HF

  • systolic/R: BB, ACE-i/Arb/ARNI, thiazide/loop, aldosterone antagonist
    • monitor renal, Cr, KCl
    • hydralazine w/ isosorbide
    • ivabradine
    • digoxin
    • ICD (if EF< 35%)
  • diastolic/P: lifestyle, diuretics, treat comorbidities (DM, HTN, CAD)
79
Q

Stage D HF management

A

consider LVAD/transplant

palliative care

80
Q

when to refer for heart failure?

A
  • sx’s refractory to standard therapies
  • new stable arrhythmias
  • new coronary ishcemia on EKG
  • ALL young pt’s w/ dilated cardiomyopathy or worsening sx’s
81
Q

when to hospitalize HF?*

A
  • new onset HF with signs of congestion/fluid overload
  • suspect infarction or ischemia
  • pulmonary edema (pink frothy sputum)
  • O2 < 90%
  • unstable pts
  • ACS/MI
  • new arrhythmia w/ hemodynamic instability
82
Q

Peripheral artery disease (PAD) screening

A
  • All over 65
  • all over 50 with hx of smoking or diabetes
  • all with suspected PAD sx’s + non healing wounds
83
Q

PAD hallmark sign and presentation *

A
  • discomfort with activity “tiredness”, “giving way”, “soreness” “pain”
  • hallmark: intermittent claudication
    • tightening, cramping pain from exercise and alleviated by rest
    • calf most common, thigh, butt (iliac artery obstruction/Leriche syndrome)
  • severe: pain @ rest/awaken at night (alleviated by gravity)
84
Q

*PAD exam

A
  • distal hairloss
  • shiny skin
  • absent femoral pulses/femoral bruit
  • muscle atrophy
  • advanced:
    • dependent rubor (pale with elevate for 30 secs, then when dependent, deep red ensues
      • longer it takes for rubber to get = worse ischemia
      • skin ulcers
85
Q

PAD initial diagnostic & for whom?

A
  • resting arterial brachial index (ABI): portable doppler + sphygmomanometer cuff
  • used in pts with 1 or more of:
    • exertion leg sx’s
    • non healing lower extremity wounds
    • hx with PAD in 65 ys +
    • sx in pt 50 yrs + with smoking hx or diabetes
86
Q

ABI interpretation and scores

A
  • ABI lower in affected extremity
  • measure brachial artery with dorsals pedis and posterior tibial arteries
  • <0.9: PAD
  • 0.75 - 0.5: claudication
  • < 0.5: rest with pain and/or tissue loss
  • 1-1.3: normal
  • >1.4: calcified arteries → further assess with toe brachial index

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