ACS (Acute Coronary Syndrome)
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Definition Spectrum of problems ranging from unstable angina to MI
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Symptoms Crushing pain/pressure; radiation to jaw, back, and left arm; SOB, diaphoresis, N/V; impending sense of doom
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Most common etiology of MI Preexisting atherosclerotic plaque ➔ thrombus formation ➔ prolonged myocardial ischemia ➔ MI
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EKG changes Acute MI: progression from peaked T- waves ➔ ST-degment elevation/depression ➔ Q-wave ➔T-wave inversions (hours-days)
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Laboratory Tests EKG (within 10 min), troponin levels, CK:CK-MB ratio, MRI with gadolinium
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Stable Angina Reproducible pain, improved with rest, lasts <10min,
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UA/NSTEMI Occurs more often with less activity, not relieved with NTG, lasts >10min, EKG changes
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STEMI Complete occlusion, EKG changes
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Initial Treatment ONAM: Oxygen, +/- nitro, antiplatelets (ASA+P2Y12), morphine (PRN), EKG monitoring, IV access
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Discharge Treatment 1) ASA (life)
2) P2Y12 (1yr)
3) Statin
4) ß-blocker
5) ACE-I
6) Aldosterone antagonist
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Emergency Intervention Door-to-needle within 30min; door-to-balloon within 90min
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Congestive Heart Failure (CHF)
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Definition Inability of the heart to keep up the the demands on it and pump blood with normal efficiency
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Result of one or more of the following Contractile ability of heart muscle, preload and after load of the ventricle, and heart rate
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Etiology MI, pericardial disorders, valvular disorders, congenital abnormalities, and non cardiac causes (high-output heart failure from thyrotoxicosis or severe anemia)
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Clinical features of HFrEF/LHF Exertional dyspnea, non-productive cough, fatigue, orthopnea, PND, basilar rales, gallops, exercise intolerance
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Clinical features of HFpEF/RHF Distended neck veins, hepatic congestion, nausea, dependent pitting edema, *edema + hepatomegaly, (R-sided failure often caused by L-sided failure)
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Treatment 1) Loop
2) ACE-I
3) ß-blocker
4) Spironolactone
5) Hydralazine + ISDN (esp in blacks)
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Hypertension
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Primary HTN Causes 95% of cases of HTN; multifactorial pathogenesis (genetics, salt, obesity, RAAS, NSAIDs, smoking, lack of exercise, metabolic syndrome)
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Secondary HTN Narrowing of aorta, RAS, chronic steroids, Cushings syndrome, pregnancy, thyroid and parathyroid disease, primary hyperaldosteronism, parenchymal renal dz)
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Treatment Goal All ages with DM or CKD ≤140/90
Ages <60yo ≤140/90
Ages ≥60yo ≤150/90
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Treatment First line: ACE-I/ARB, CCB, thiazides
Other: alpha blockers, clonidine, guanfacine, hydralazine, minoxidil,
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Ischemic Heart Disease
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Definition Characterized by insufficient oxygen supply to cardiac muscle
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Etiology 1) Atherosclerotic narrowing (most common). 2) Constriction of coronary arteries. 3) (Rare) congenital, emboli, arteritis, dissection
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Risk Factors Metabolic syndrome, male, older age, smoking, FmHx, HTN, DM, low-estrogen state, abdominal obesity, inactivity, dyslipidemia, EtOH, low fruits/veggies (cocaine ➔ MI)
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Un/stable Angina See Above
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Prinzmetal's (Variant) Angina Caused by vasospasm at rest, exercise capacity preserved. Treated with CCBs, avoid ß-blockers
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EKG Findings Horizontal or downsloping ST-segment depression
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Treatment Lifestyle changes, nitrates (nitro and LA), B-blockers, CCB, Ranolazine, ASA/Clopidigrel, revascularization
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