Coronary Heart Disease (PEARLS) (Smarty PANCE): Non-ST-Segment Elevation MI, ST-Segment Elevation Myocardial Infarction, Angina pectoris

Unstable angina includes what?

1. Any new onset chest pain 2. Chronic angina that changes (worse, frequency, etc) 3. Angina at rest

Medical therapy for stable angina?

1. Aspirin (reduces risk of MI) 2. Statins 3. Beta blockers 4. Nitrates

What symptoms are very typical of stable angina?

1. Resolves with rest or nitro 2. Chest pain is substernal pressure/heavy 3. Pain brought on by things that increase myocardial demand (stress, exertion, drugs)

There are ___________sinuses but only ________ coronary arteries

3, 2

What is Prinzmetal or variant angina?

A clinical entity characterized by episodes of rest angina that promptly respond to short-acting nitrates and are attributable to coronary artery vasospasm

Initial treatment of NSTEMI?

All patients presenting with symptoms of Acute Coronary Syndrome will get standard (MONA) ● Morphine (IV if pain not relieved by NTG) ● Oxygen (4L/min) ● Nitroglycerine (sublingual) - 0.4 mg every five minutes for a total of three doses ● Aspirin (160-325 mg) chewed

All three types of angina can be treated with what medication?

All three can be treated with nitroglycerin

What is angina pectoris?

Angina pectoris is chest pain caused by reduced blood flow resulting in a lack of oxygen in the heart muscle.

What percentage of the coronary artery is usually blocked to produce symptoms of angina?

Angina usually occurs when the patient has greater than or equal to 70% stenosis, meaning 70% of the artery is blocked by plaque buildup.

Q waves and ST elevation in leads *I, AVL, and V2 to V6*

Anterior wall infarction

Appears at 4-6 hours, peaks at 12-24 hours and *lasts for 3-4 days*

CK/CK-MB

What is used to prevent symptoms of vasospastic angina?

Calcium channel blockers may effectively prevent symptoms.

What is the #1 risk factor for Prinzmetal variant angina?

Cigarette smoking is the #1 risk factor, substance abuse is an important risk factor often cocaine

ECG changes of Non-ST-segment elevation MI?

ECG changes such as ST-segment depression, T-wave inversion, or both may be present (no ST elevation or Q waves)

*Anterior wall Q wave infarctions* can be identified by changes in _________and ________ . ● Significant ST elevation ● V leads will show changes as well

I, aVL

*Inferior wall Q wave infarctions* can be identified by changes in ________, _________, and _____________ .

II, III, aVF

Name the three inferior leads

II, III, and aVF

Q waves and ST elevation in leads *II, III, and AVF*

Inferior wall infarction

ST elevations in leads *I, AVL, and V5 to V6*

Lateral wall infarction

A blockage of which artery causes an anterior wall MI?

Left anterior descending (LAD)

A blockage of which artery causes lateral wall MI?

Left circumflex artery

What is Non-ST-segment elevation MI?

Non-ST-segment elevation MI (NSTEMI, subendocardial MI) is myocardial necrosis (evidenced by cardiac markers in blood; troponin I or troponin T and CK will be elevated) without acute ST-segment elevation or Q waves

Drugs to avoid in vasospastic angina?

Nonselective beta blockers, such as propranolol can exacerbate vasospasm and should be avoided

On ECG does stable and unstable angina may show ST elevation or depression?

On ECG stable & unstable angina show ST depression - ST depressions indicate ischemia is isolated to the subendocardium!

NSTEMI vs. unstable angina?

Only difference is elevated cardiac enzymes in NSTEMI ● In unstable angina, the heart tissue is alive but ischemic (starving for oxygen) in MI tissue has begun to necrose (die) - thus elevation in enzymes

NSTEMI vs. unstable angina?

Only difference is elevated cardiac enzymes in NSTEMI. Unstable angina and NSTEMI differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins)

GOLD STANDARD treatment for STEMI best if within 3 hours (90 minutes) of sx onset

PCI (Percutaneous Coronary Intervention)

Pain relief treatment for stable angina includes rest and (medication) nitroglycerin

Pain relief treatment for stable angina includes rest and nitroglycerin

What is the difference in early medical regimen of NSTEMI, unstable angina, and STEMI?

Patients with unstable angina (UA) or acute non-ST elevation myocardial infarction (NSTEMI) should be treated with an early medical regimen similar to that used in an acute ST elevation MI (STEMI) with one exception: There is no evidence of benefit (and possible harm) from fibrinolysis

Do people with stable angina have pain at rest?

People with stable angina do not have pain at rest

The _____________ supplies the inferior part of the heart

RCA

the __________________supplies the right ventricular part of the heart

RCA

What makes stable angina different than unstable angina and vasospastic angina?

Rest tends to relieve stable angina, but not the other two types ● Stable angina: Pain during exercise or stress. It is predictable, relieved by rest and/or nitroglycerine ● Unstable angina: Pain during exercise or stress or at rest that doesn't go away. (Previously stable and predictable symptoms of angina that are more frequent, increasing, or present at rest) ● Prinzmetal variant angina (vasospastic): Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot

On ECG does vasospastic (prinzmetal) angina may show ST elevation or depression?

ST elevation - indicating transmural ischemia

________________elevation is required for STEMI. Within 2 minutes to hours.

ST segment

Substernal chest pain radiating to the neck and arm with ST-segment elevations > 1mm in > 2 contiguous leads on ECG and evidence of myocardial necrosis (cardiac markers in blood; troponin I or troponin T and elevated CK). What's the diagnosis?

ST-Segment Elevation Myocardial Infarction (STEMI)

Chest pain or discomfort that most often occurs with activity or emotional stress relieved by rest. What's the diagnosis?

Stable angina

Symptoms of Prinzmetal variant angina?

Symptoms are anginal discomfort occurring mainly during rest, often at night or early morning, and only rarely and inconsistently during exertion

_______________alterations is often the *first sign of myocardial injury*. Not specific.

T wave

The classic finding with angina is ischemia in which part of the heart tissue?

The classic finding with angina is subendocardial (deepest layer and farthest away from the blood supply) ischemia

What is the gold standard diagnostic test for Prinzmetal variant angina?

The gold standard is coronary angiography with the injection of provocative agents (ergonovine or acetylcholine) into the coronary artery.

What is the most common cause of stable angina?

The most common cause of stable angina is atherosclerosis of one or more coronary arteries. Other causes include HOCM, Aortic Stenosis, and HTN

What two factors of Prinzmetal angina should help you distinguish it from classical angina?

The quality of the chest pain is indistinguishable from classical angina associated with obstructive CAD; however, the context in which it occurs differs. Patients with vasospastic angina report that their episodes are predominantly at rest and that many occur from midnight to early morning

What are the three types of angina?

There are three types: stable angina, unstable angina, and vasospastic angina

Appears at 2-4 hours, peaks 12-24 hours and *lasts for 7-10 days*

Troponin

Troponins increase in ______ hours and peak at ______ hours and return to normal after _____ days.

Troponin are the most sensitive and specific ● Increase: 3-5 hours ● Peak: 24-48 hours ● Normal: 5 to 14 days

Chest pain or discomfort that most often occurs with activity or emotional stress. Previously stable and predictable symptoms of angina that are more frequent, increasing, or present at rest. What's the diagnosis?

Unstable angina

What is used for the acute treatment of vasospastic angina?

Usually, sublingual nitroglycerin promptly relieves variant angina.

Which EKG leads are used to diagnose an anterolateral MI?

V5 and V6

What is the new accepted name for Prinzmetal or variant angina?

Vasospastic angina was previously referred to as Prinzmetal or variant angina

Should a patient with unstable angina be worked up for a myocardial infarction?

YES, of course!

You will have a ST ___________________ in a subendocardial injury

depression

You will have a ST _______________ in a transmural (epicardial) injury

elevation

Myocardial _______________ is an area of non-functioning and possibly dead cardiac myocytes

infarction

If you have a posterior MI, the changes are ________________ ● Look at *V1-V3 and observe deep R wave and ST segment depression*

inverted

Myocardial ___________ is a state of reduced oxygen supply or increased demand for an area of the heart

ischemia

The ______________supplies the posterior part of the heart

left circumflex artery

T symmetric wave inversion is a sign of myocardial ischemia in the ________________ layer

subendocardial

The _____________ layer of the heart is most susceptible to ischemia

subendocardial

*Q wave changes* are often associated with ____________STEMI. ● Evolve over the first day of injury or so.

transmural

When ischemia is _______________, the T waves may become *hyperacute* (tall and peaked)

transmural

CK-MB increases in ____ hours, peaks at _____ hours, and returns to normal at _____ hours

● Increases: 4 to 8 hours ● Peak: 24 hours ● Normal: 2-3 days

Absolute contraindications for fibrinolytic use in STEMI

● Prior intracranial hemorrhage (ICH) ● Known structural cerebral vascular lesion. ● Known malignant intracranial neoplasm. ● Ischemic stroke within 3 months. ● Suspected aortic dissection. ● Active bleeding or bleeding diathesis (excluding menses)

STEMI vs. NSTEMI vs. unstable angina

● STEMI = ST elevation + cardiac markers ● NSTEMI = ST depression, T-wave inversions (no ST elevations) + cardiac markers ● Unstable angina = +/- ST depression, T-wave inversions (no ST elevations) & NO cardiac markers

NSTEMI vs STEMI?

● STEMI: transmural (involves the full thickness of the myocardium) ● NSTEMI: subendocardial (deep layer of left ventricular muscle)