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For both stable angina and acute coronary syndromes the quality of chest pain
is described by the patient as xxxxxxxxxxx
"tightness," "heaviness," or "pressure."
Also, in inferoposterior wall ischemia,
vagal reflexes may cause xxxxxxx
bradycardia and hypotension, presenting as dizziness
or fainting.
"Sharp" or "knife-like" chest pain and pain that the patient can pinpoint to the
"exact area" is less likely to be related to xxxxxx
ischemia or infarction, especially if the chest
pain is reproduced by changes in position or palpation.
Myocardial infarction is associated with pain that lasts more thanxxxx
20-30 minutes in
duration.
Response of chest pain to nitroglycerin (within a few minutes) is most consistent
with ............
transient ischemia or esophageal spasm.
Chest pain that worsens with nitroglycerin
sometimes occurs with .....................
gastroesophageal reflux disease.
5. Acute coronary syndromes in women present with atypical symptoms:
dyspnea,
shortness of breath, fatigue. This may be due to the older age group in which myocardial
ischemia and infarction occur in women.
.............n should alert the clinician to
a potentially life-threatening process.
Diaphoresis, tachypnea, and anxious expressio
a difference of over xxxxxxxx systolic suggests aortic dissection and is present in about
70% of cases.
20 mm Hg
findings consistent with ischemia
(ST depression and/or T wave inversion)
MI diagnostic
findings
(ST elevation or Q waves),
CK-MB isoenzyme (CK-MB): is cardiac specific and is useful for the early diagnosis of acute
myocardial infarction. CK-MB typically is detectable in the serum 111111 after the onset
of ischemia, peaks in 22222222 hours, and normalizes in333
1)4-6 hours
2)12-24
3) 2-3 days
CK-MB subforms: CK-MB may be further characterized into subforms (or isoforms).
CK-MB2 is found in 11111 and CK-MB 1 is found in 2222 The CK-MB subform
is not routinely used.
1)myocardial tissue,
2)plasma.
They are the preferred markers for the diagnosis of myocardial injury.
"cardiac troponins."
Patients with a normal CK-MB level but elevated troponin levels are
considered to have xxxxxxxxxxx
sustained minor myocardial damage, or microinfarction
An elevated------------------is helpful in identifying patients at increased risk for death
or the development of acute myocardial infarction.
troponin T or I level
progression of cardiac enzymes
Differentiating Features of Costochondritis
Pain exacerbated with inspiration;
reproduced with chest wall palpitation
Differentiating Features of Hiatal hernia
Reflux of food; relief with antacids
Differentiating Features of GERD
Acid reflux; relief with antacids
Differentiating Features of Peptic ulcer
Epigastric pain worse 3 h after eating
Differentiating Features of Gallbladder disease
Right upper quadrant abdominal pain
and tenderness
Differentiating Features of Cardiovascular Disorders
Differentiating Features
Differentiating Features of Myocardial Infarction
Pain more severe, usually more than 20
min in duration
Differentiating Features of Aortic stenosis
Typical systolic ejection murmur
Differentiating Features of Myocarditis Pain
is usually vague and mild if present
Differentiating Features of Pericarditis Pain
is sharper, pain worse with lying
down and relieved by sitting up
Pain is sharp, tearing, often occurs in back
Dissecting aortic aneurysm
Transient pain, midsystolic click murmur, and
young female with no risk factors
Mitral valve prolapse
Differentiating Features
Pulmonary Disorders
Tachypnea, dyspnea, cough, pleuritic pain,
hemoptysis
Pulmonary embolus-infarction
Signs of right ventricle (RV) failure
Pulmonary hypertension
•
Sudden onset of pain and dyspnea
Pneumothorax
Pain is sharp, tearing, and extremely severe; typically radiates to back; loss
of pulses or aortic insufficiency often develop; mediastinum is widened on chest x-ray; MI
may occur if dissection extends into coronary artery; diagnosis confirmed by MRI, CT scan,
transesophageal echocardiogram, or aortography.
Aortic Dissection
Dyspnea, tachycardia, and hypoxemia are prominent; pain is usually
pleuritic, especially when pulmonary infarction develops; EKG is usually nonspecific but may
show S wave in lead I, Q wave in lead III, or inverted T wave in lead III; diagnosis confirmed
by spiral chest CT, lung scan, or pulmonary angiogram.
Pulmonary Embolism.
May be preceded by viral illness; pain is sharp, positional, pleuritic, and relieved by
leaning forward; pericardial rub often present; diffuse ST elevation occurs without evolution of
Q waves; CK level usually normal; responds to anti-inflammatory agents.
Pericarditis.
May be preceded by viral illness; pain is generally vague and mild if present; the
levels of total CK and the MB fraction of CK (CK-MB) are often elevated; conduction abnormalities
and sometimes Q waves occur.
Myocarditis.
. Most common cause of chest pain
Musculoskeletal Disorders
pain is atypical, stabbing, localized, may be pleuritic; reproduced by
motion or palpation; EKG changes absent
Musculoskeletal Disorders
Pain is sharp and increases on inspiration; friction rub or dullness may be present;
other respiratory symptoms and underlying pulmonary infection usually present.
Pleuritis
Why MI may occur in Aort dissection
if dissection extends into coronary artery ST depressions occur
Risk factors for Aort dissection.
Pregnancy Marfan Aort coarctation
first step in management of Aort dissection
Antihypertensive therapy.
----------- is the most useful test in the evaluation of
the cause of chronic chest pain when IHD (stable angina) is a consideration
The exercise treadmill test (exercise stress test)
An exercise stress is considered positive for myocardial ischemia when:
large (more than
2 mm) ST-segment depressions or hypotension (a drop of more than 10 mm Hg in systolic
pressure) occur either alone or in combination
Exercise stress testing is contraindicated when it may place the patient at increased risk of
cardiac instability, as in the setting of
aortic dissection, acute myocardial infarction, unstable
angina, severe congestive heart failure, uncontrolled sustained ventricular arrhythmias,
symptomatic supraventricular arrhythmia, significant aortic stenosis, hypertrophic cardiomyopathy,
or severe uncontrolled hypertension.
Nuclear stress test:
This is a stress test in which a radioactive substance is injected
into the patient and perfusion of heart tissue is visualized. The perfusion pictures
are done both at rest and after exercise. An abnormal amount of thallium will be
seen in those areas of the heart that have a decreased blood supply. Compared to
regular stress tests, the nuclear stress tests have higher sensitivity and specificity
(82% sensitivity, 95% specificity vs. 67% sensitivity, 70% specificity). These tests are
also not affected by baseline changes in the ECG (LBBB, ST-segment depression at
baseline, etc.).
Dobutamine or Adenosine Stress Test:
This test is used in people who are unable to
exercise. A drug is given to induce tachycardia, as if the person were exercising.
Stress echocardiogram:
The stress echocardiogram combines a treadmill stress test
and an echocardiogram (ECHO). The latter can recognize abnormal movement of the
walls of the left ventricle (wall motion abnormalities) that are induced by exercise.
For individual episodes of angina, xxxxxxxxx typically alleviate
the pain within three minutes.
nitroglycerin (NTG) sublingual tablets
Long-term management is with xxxxxxxx yyyyyyyy either alone or in combination.
long-acting nitrates or beta
blockers,
Other medications patients with stable angina
should be taking, unless contraindicated, include xxxxxxx yyy
aspirin and statins (for lipid lowering).
Invasive techniques: Cardiac catheterization is also used in patients with stable angina for
(I) diagnosis and (2) prognosis/risk stratification. Angiography is an appropriate diagnostic
test when noninvasive tests are
contraindicated or inadequate due to the patient's illness or
physical characteristics (e.g., morbid obesity, COPD).
Cardiac angiography is also used after
conventional stress test are positive to identify patients that will benefit form
stent placement
or bypass surgery.
Target goals for hyperlipidemic patients with
coronary artery disease include:
• LDL—less than 100 mg/dL
• HDL—40 mg/dL or greater
• Triglycerides—less than 150 mg/dL
The optimal LDL-cholesterol goal is considered to be xxxx for patients considered
to be very high risk.
less than 70 mg/dL
very high risk. These include patients with established cardiovascular disease
plus any of the following:
(i) multiple major risk factors, such as diabetes, smoking, HTN;
(2) metabolic syndrome-associated risk factors (triglycerides greater than 200 mg/dL, HDL
less than 40 mg/dL); and (3) patients with acute coronary syndromes. Bottom line: patients
with chronic stable coronary artery disease will likely need to be on statin therapy, unless
contraindicated, regardless of their lipid levels.
Target goals for hyperlipidemic patients with
coronary artery disease include:
• LDL—less than 100 mg/dL
• HDL—40 mg/dL or greater
• Triglycerides—less than 150 mg/dL
The optimal LDL-cholesterol goal is considered to be xxxx for patients considered
to be very high risk.
less than 70 mg/dL
very high risk. These include patients with established cardiovascular disease
plus any of the following:
(i) multiple major risk factors, such as diabetes, smoking, HTN;
(2) metabolic syndrome-associated risk factors (triglycerides greater than 200 mg/dL, HDL
less than 40 mg/dL); and (3) patients with acute coronary syndromes. Bottom line: patients
with chronic stable coronary artery disease will likely need to be on statin therapy, unless
contraindicated, regardless of their lipid levels.
Target goals for hyperlipidemic patients with
coronary artery disease include:
• LDL—less than 100 mg/dL
• HDL—40 mg/dL or greater
• Triglycerides—less than 150 mg/dL
The optimal LDL-cholesterol goal is considered to be xxxx for patients considered
to be very high risk.
less than 70 mg/dL
very high risk. These include patients with established cardiovascular disease
plus any of the following:
(i) multiple major risk factors, such as diabetes, smoking, HTN;
(2) metabolic syndrome-associated risk factors (triglycerides greater than 200 mg/dL, HDL
less than 40 mg/dL); and (3) patients with acute coronary syndromes. Bottom line: patients
with chronic stable coronary artery disease will likely need to be on statin therapy, unless
contraindicated, regardless of their lipid levels.
Target goals for hyperlipidemic patients with
coronary artery disease include:
• LDL—less than 100 mg/dL
• HDL—40 mg/dL or greater
• Triglycerides—less than 150 mg/dL
The optimal LDL-cholesterol goal is considered to be xxxx for patients considered
to be very high risk.
less than 70 mg/dL
very high risk. These include patients with established cardiovascular disease
plus any of the following:
(i) multiple major risk factors, such as diabetes, smoking, HTN;
(2) metabolic syndrome-associated risk factors (triglycerides greater than 200 mg/dL, HDL
less than 40 mg/dL); and (3) patients with acute coronary syndromes. Bottom line: patients
with chronic stable coronary artery disease will likely need to be on statin therapy, unless
contraindicated, regardless of their lipid levels.
xxxxxx is beneficial in patients with ST elevation MI (STEMI), but is not
effective in UA or NSTEMI and may be harmful
Thrombolytic therapy
Coronary arteriography, performed in the
acute period following NSTEMI, demonstrates that the infarct-related artery is xxxx
in 60 to 85 percent of cases.
not occluded
The nonoccluding thrombi that are present are primarily xxxxxx and therefore less likely to respond to thrombolytic therapy, in contrast
to being almost always yyyy in patients with STEMI.
x) grayishwhite
(platelet-rich)
y)fibrin-rich
In addition, microvascular perfusion
is often reduced in patients with UA or NSTEMI; as a result, the ongoing mechanism of
ischemia is more likely xxxxxx than yyyyyy
x) thrombus-related embolization
y) epicardial vessel occlusion.
Unstable angina is sometimes referred to as xxxxx or yyyy angina
x "crescendo"
y "preinfarction"
angina of increasing severity, frequency, duration;
Unstable angina
angina showing increasing
resistance to nitrates
Unstable angina
angina occurring at rest.
Unstable angina
Experts also regard any new-onset angina
as
unstable
Sudden change in the pattern of angina usually means
a physical change within
the coronary arteries, such as hemorrhage into an atherosclerotic plaque or rupture of a
plaque with intermittent thrombus formation.
In
fact, untreated unstable angina progresses to xxxx in 50% of cases, thus the patient with new
onset or unstable angina should be hospitalized for intensive medical treatment.
x) MI
Most patients with NSTEMI have xxxxx physical examination.
a normal
An abnormal ECG, particularly
xxxxxx , or yyyyy will confirm
the NSTEMI diagnosis
x) dynamic ST-segment deviation (>0.5 mm)
y) new T-wave inversion (>2 mm)
but the ECG may be normal or show minor changes in up to 50% of cases.
NSTEMI