CHD & ACS

Question 1

Ddx for chest pain

Answer 1

• Nonischemic

- Noncardiovascular: Pulmonary, GI, musculoskeletal

Question 2

Classic ACS initial therapy “MONA”

Answer 2

• Morphine
• O2
• Nitroglycerin
• Aspirin

Question 3

Define angina

Answer 3

Chest, jaw, shoulder, arm discomfort due to ischemia

Question 4

Define typical angina

Answer 4

Substernal chest discomfort w/ quality & duration

• Provoked by exertion or stress
• Relieved w/ rest or nitroglycerin

Question 5

Define atypical angina

Answer 5

Having only 2 of the typical characteristics

- May be pleuritic, reproduced by palpation or movement, constant & lasting days, fleeting pain lasting seconds

Question 6

Stable angina

Answer 6

• develops w/ predictable amount of exertion
• similar to typical angina
• short duration
• resolves w/ rest or meds

Question 7

MI

Answer 7

Rise/fall of cardiac biomarker values w/ at least 1 value above the 99th percentile & 1 of the following:

1. sx of ischemia
2. ST segment T wave changes or new LBBB
3. pathological Q waves
4. loss of myocardium or new RWMAs
5. thrombus

Question 8

Ischemia-guided strategy, when is invasive eval used?

Answer 8

Invasive eval, used if pt:

• fails med therapy
• has evidence of ischemia on stress test
• has high risk

Question 9

NSTE-ACS pathogenesis

Answer 9

Imbalance of myocardial O2 consumption & demand –> ischemia/infart

Question 10

NSTE-ACS etiologies

Answer 10

• Coronary artery obstruction
• Vasospasm (Prinzmetal’s angina)
• Coronary embolism
• Dissection
• Nonobstructive causes

Question 11

Possible PE findings for ACS?

Answer 11

• Levine’s sign (bringing hand to heart)
• New S4
• Paradoxal splitting of S2
• Pericardial friction rub
• CHF/shock

Question 12

Initial ACS dx studies

Answer 12

• ECG within 10 mins of arrival in ED
• Obtain hx (1st step in risk stratification)
• May repeat ECG 12-30 mins for 1st hr
• Serum biomarkers
• CBC, BMP, coagulation panel, cholesterol
• B-type natriuretic peptide (BNP)
• CXR

Question 13

When should troponin be measured?

Answer 13

At presentation & 3-6 hrs after sx onset in all pts who present w/ sx consistent w/ ACS
- Should be repeated 6 hrs after sx onset in those w/ high suspicion for ACS even if troponin is negative (bc this does not mean that there is no ischemia!)

Question 14

What is not useful for dx of ACS?

Answer 14

CK-MB & myoglobin

Question 15

Causes of elevated troponin

Answer 15

• Tachy/brady
• Cardiogenic, hypovolemic, septic shock
• HTN w/ or w/out LVH
• HF
• Pulmonary embolism or HTN
• Sepsis
• Renal failure

Question 16

What can be used to dx reinfarction & assess reperfusion?

Answer 16

CK-MB

Question 17

What models can be used in the management of NSTE-ACS?

Answer 17

•  TIMI Risk Score *
•  GRACE Risk Model *
•  PURSUIT Risk Score
•  GUSTO Risk Score
•  HEART Score for MACE *
•  EDACS

Question 18

TIMI risk score values

Answer 18

• Low risk = 0-2
• Intermediate risk = 3-4
• High risk = 5-7

Question 19

In the TIMI risk score model, what equals 1 point each?

Answer 19

• Age ≥ 65
•  ≥ 3 risk factors for CAD
  - Known CAD
  - ASA use in past 7 days
  - Severe angina (≥ 2 episodes within 24 hrs)
  - ST depression ≥ 0.5
  - Positive cardiac biomarkers

Question 20

Who should be admitted to hospital?

Answer 20

• Recurrent sx
• Ischemic changes
• Elevated troponin
• Intermediate to high risk

Question 21

NSTE-ACS standard med therapies

Answer 21

• Supplemental O2
• Anti-platelet
• Statin
• Nitroglycerin
• Analgesics (NSAIDS contraindicated)

Question 22

What med is contraindicated?

Answer 22

NSAIDs

Question 23

Types of anti-platelet therapy

Answer 23

• Aspirin (Non-enteric coated, chewable)

- P2Y12 Inhibitor (Clopidogrel, Prasugrel, Ticlopidine, Ticagrelor)

Question 24

Types of anticoagulation

Answer 24

• Indirect thrombin inhibitors

- Direct thrombin inhibitors

Question 25

Beta blockers

Answer 25

- Decreases myocardial contraction & O2 demand | - Metoprolol, carvedilol, bisoprolol

Question 26

Calcium channel blockers

Answer 26

- Nondihydropyridine (verapamil, diltiazem) | - Initial therapy if ongoing angina

Question 27

Aldosterone antagonist

Answer 27

- For pts post-MI in the absence renal dysfunction or hyperkalemia

Question 28

Features of unstable angina

Answer 28

- Develops at rest or w/ minimal exertion - Change in typical pattern - More severe/ lasts longer - May not resolve w/ rest or meds

Question 29

What is unstable angina caused by?

Answer 29

Insufficient coronary blood flow, w/out evidence of myocardial necrosis

Question 30

NSTEMI & STEMI

Answer 30

Angina w/ elevated cardiac biomarkers | - Indicates MI, w/ or w/out ST deviation

Question 31

Coronary disease spectrum

Answer 31

- Ischemia = stable & unstable angina - Infarction = STEMI & NSTEMI - ACS = unstable angina, STEMI, & NSTEMI

Question 32

Baseline risk factors for ACS

Answer 32

- Male > female - Age - Family hx - Prio hx of CAD - Kidney disease - DM* - HLD* - HTN* - Tobacco*

Question 33

When is troponin elevated & how long does it persist?

Answer 33

- As early as 2-4hrs, at tops 12hrs | - May persist 14 days or longer

Question 34

What should be administered to all pts w/ possible NSTE-ACS at presentation?

Answer 34

Non-enteric coated, chewable ASA