OnlineMedEd: Cardiology - "CAD"

Question 1

For asymptomatic CAD, go through pain, relief, biomarkers, ST changes, and percent occlusion.

Answer 1

• Pain: absent
• Relief: N/A
• Biomarkers: absent
• ST changes: absent
• Percent occlusion: less than 70%

This would be occlusion discovered incidentally (say, on an angiogram).

Question 2

For stable angina, go through pain, relief, biomarkers, ST changes, and percent occlusion.

Answer 2

• Pain: with exertion
• Relief: with rest
• Biomarkers: absent
• ST changes: absent
• Percent occlusion: more than 70%, less than 90%

Question 3

For unstable angina, go through pain, relief, biomarkers, ST changes, and percent occlusion.

Answer 3

• Pain: at rest
• Relief: nothing
• Biomarkers: absent
• ST changes: absent
• Percent occlusion: 90% or more

Question 4

For NSTEMI, go through pain, relief, biomarkers, ST changes, and percent occlusion.

Answer 4

• Pain: at rest
• Relief: nothing
• Biomarkers: present
• ST changes: absent
• Percent occlusion: 90% or more

Question 5

For STEMI, go through pain, relief, biomarkers, ST changes, and percent occlusion.

Answer 5

• Pain: at rest
• Relief: nothing
• Biomarkers: present
• ST changes: present
• Percent occlusion: 100% or more

Question 6

Review Dustyn’s ischemia breakdown for the differences in types of CAD.

Answer 6

• SA, UA, and NSTEMI are types of demand ischemia; when the demand increases beyond the ability of the artery to supply, pain and ischemia result.
• STEMI is supply ischemia (because the vessel is completely blocked).

Question 7

What are the Diamond criteria?

Answer 7

Features of the HPI that make angina more likely to be cardiac in origin:

• substernal or left-sided
• worse with exertion
• relieved by NTG
• 3/3 = typical angina
• 2/3 = atypical angina
• 0-1/3: nonanginal pain

Question 8

List the risk factors for CAD.

Answer 8

• DM
• HLD
• HTN
• Obesity
• Family history
• Smoker
• Age (M greater than 45, W greater than 55)

Question 9

Describe the characteristics that make chest pain more likely to be cardiac.

Answer 9

• Non-positional
• Non-pleuritic
• Non-tender

Question 10

Review the workup of chest pain.

Answer 10

• 1) ECG: if ST elevations are present (i.e., this is a STEMI), take immediately to the cath lab
• 2) Troponins: if ST elevations are absent but troponins are elevated (NSTEMI), then take to cath lab soon but not immediately
• 3) Stress test: if ECG is normal, troponins are not elevated, but the stress test is positive, then take electively to the cath lab

If all three are negative then it is likely non-cardiac in origin.

Question 11

Stress echocardiography looks for _______________.

Answer 11

tissue that moves at rest but stays still during the stress test; this indicates at-risk tissue

Question 12

Describe the indications for catheterization versus bypass.

Answer 12

• 3 or more vessels occluded: bypass

* 1 or 2 vessels occluded: stent

Question 13

Review the treatment for acute coronary syndrome.

Answer 13

MONA BASH C
• Morphine
•Oxygen
• Nitroglycerin
•ASA
•Beta-blocker
• ACE-inhibitor
• Statin
•Heparin 
•Clopidogrel (or another antiplatelet drug) 

Note: all people with ACS should get the ABAS portion. Those with pain should be offered nitroglycerin. Those with stents should be given clopidogrel. Heparin for people with high index of suspicion for NSTEMI.

Question 14

Describe the role of tPA.

Answer 14

The door-to-balloon time is 90 minutes. If you cannot get someone to a cath lab in under 90 minutes, then give tPA. You must give tPA in less than 60 minutes.