CAD and ACS

Question 1

What are the complications of CAD?

Answer 1

Angina pectoris
MI
HF
Arrhythmias

Question 2

What are the modifiable major risk factors of CAD?

Answer 2

Elevated serum lipid levels (high LDL and low HDL)
Elevated blood pressure (BP)
Tobacco use
Physical inactivity
Obesity

Question 3

What are the 2 common medication therapies used for CAD?

Answer 3

Cholesterol-lowering medication therapy (i.e., statins, fibrates, PCSK9 Inhibitors)

Antiplatelet therapy (i.e., aspirin)

Question 4

Differentiate Chronic Stable angina from Unstable angina

Answer 4

Chronic Stable angina
- predictable set of symptoms that are aggravated by predictable activities
- may experience indigestion or a burning sensation in the epigastric region

Unstable angina
- chest pain that is new in onset, occurs at rest, or has a worsening pattern
- not relieved by NTG

Question 5

Explain the MoA and role of NTG in managing Stable Angina

Answer 5

First-line therapy for chronic stable angina

Produce effects by:
1. Dilating peripheral blood vessels = reduced cardiac workload & thus reduced myocardial O2 demand
2. Dilating coronary arteries and collateral vessels

Side effects include increased HR, headache, dizziness, flushing and orthostatic hypotension

Question 6

Explain the MoA and role of Beta Blockers in managing Stable Angina

Answer 6

decrease HR, SVR, and BP which reduces myocardial oxygen demand

Question 7

Explain the MoA and role of Calcium Channel Blockers in managing Stable Angina

Answer 7

cause systemic vasodilation with decreased SVR, decreased myocardial contractility, and coronary vasodilation

Question 8

Explain the role of Angiotensin inhibitors in managing Stable Angina

Answer 8

used in certain high-risk patients such as those with diabetes, significant CAD or previous MI

Question 9

What is Acute Coronary Syndrome?

Answer 9

umbrella term for: Unstable Angina, NSTEMI, and STEMI

Associated with deterioration of an atherosclerotic plaque that was once stable

Question 10

What are the clinical manifestations of a MI?

Answer 10

Severe pain not relieved by rest, nitroglycerin, or position change; commonly occurs in early morning hours
- Common locations are substernal, retrosternal or epigastric areas, may radiate to the back, jaw, neck or arms

shortness of breath, confusion, dizziness, skin that may be ashen, clammy, cool to touch, nausea and vomiting, fever

Question 11

What are the three complications of an MI?

Answer 11

Dysrhythmias
Heart failure
Cardiogenic shock

Question 12

What are the diagnostic studies of Unstable Angina and MI?

Answer 12

Serum cardiac markers – troponin, cardiac enzymes (CK)

ECG – changes in QRS complex, ST segment and T wave caused by ischemia and infarction

STEMI – may see pathological Q wave
NSTEMI or UA – usually no Q wave

Coronary angiography – evaluate the extent of disease and determine appropriate treatment modality, PCI may be performed at this time

Question 13

Management of ACS

Answer 13

Establish IV access
Sublingual nitro and ASA
Morphine IV if pain is unrelieved by NTG
Oxygen at 2-4L/min
Continuous EKG monitoring
Vital signs
Bed rest
Anticoagulants/antiplatelets

Question 14

Explain the MoA and role of Heparin in managing ACS

Answer 14

IV unfractionated - prevents formation of new clots
Use with unstable angina reduces the risk of MI
Bolus IV, then continuous infusion; dose based on results of aPTT
-> therapeutic range: 2- 2.5x the normal aPTT

Subcutaneous low molecular weight heparin may be used instead of IV unfractionated heparin, eliminates the need for monitoring aPTT