4AnginaChest pain that occurs when the coronary arteries do not deliver an adequate amount of oxygen-rich blood to the heartCategorized as stable, unstable, and Variant (Prinzmetal’s )
5Stable Angina Clinical findings of stable angina: Substernal , high pressure/heavy feelingDuration from 1 – 5 minutesInstigated by physical exertionRelieved with rest or nitrates
6Unstable Angina Clinical findings of Unstable Angina: Occurs even at restunexpectedMore severe and lasts longer than stable angina, maybe as long as 30 minutesMay not disappear with rest or use of nitrates
7Variant AnginaTransient coronary vasospasm that is associated with a fixed atherosclerotic lesion (75%)Pt tends to be younger and in seemingly good healthOccurs at rest and and associated with ventrcular dysrhythmiasNitrates and CCB’s are often effective
8DiagnosisResting EKG – normal in pts with Stable Angina, ST/T wave changes in unstable Angina and Variant AnginaStress Echo-detect ischemia, asses LV function and valve disease
10Myocardial Infarction Interruption of blood supply which causes necrosis of the myocardium.Atheromatous plaque ruptures into lumen and thrombus forms on top of the lesion causing occlusionMI has a 30% mortality rate.
11Myocardial Infarction Clinical Features:Crushing substernal chest pain(usually >30 minutes)Radiation to arms, neck, jaw, back (Left side)Diaphoresis, Nausea, Vomiting, Dyspnea, Syncope
12Diagnosis EKG changes: ST elevation – transmural injury and can be diagnostic of acute infarctST depression – Sunbendocardial injuryQ wave – evidence for necrosis, usually indicative of an old MI. Not seen acutely
14Diagnosis Cardiac enzymes – Gold Standard. 3 sets q8 in 24 hours CKMB – increases within 4-8 hours, peaks at 24hrs, and returns to normal hrs laterTrop I – More specific/sensitive than CKMB.TropI falsely increased in Renal failure
15TreatmentAdmit pt to CCU, Insert IV, , administer oxygen, nitrates, morphineAspirin, b-blockers, ACE Inhibitors reduce mortalityLovenox can slow progression of thrombosis.Cardiac Rehab- exercise + lifestyle changes post MI
16Pericarditis Inflammation of fibrous sac which covers the heart Causes: Viral Infection (Coxsackie B, Echovirus, Hep. A/B) MI, Uremia,Pts usually recover in 1-3 weeks
17Pericarditis Clinical Features: Pleuritic chest pain that is positional(worsened by lying down, inspiration). Pain is releived by sitting up + leaning forwardFriction Rub – scratching, high-pitched sound caused by rubbing of visceral and parietal pleura
18Pericarditis Diagnosis EKG – ST elevation and PR depression , then ST returns to normal, Twave inverts, then returns to normal.Treatment: Treat underlying cause and offer NSAIDS for pain
19GERDInaappropriate relaxing of LES causes backwards flow of stomach contents into esophagus.Contributing factors: ETOH, coffee, fatty food intake, increased age, and Hiatal Hernia
21GERDDiagnosis:Endoscopy w/ Biopsy- Can detect cancer complication or GERD24 hr pH monitoring of LE – Gold Standard. Highly specific/sensitive
22GERD Treatment: Phase I- diet changes + antacids Phase II – Add H2 blocker (Ranitidine)Phase III – Switch to PPI if symptoms don’t resolvePhase IV – Add pro – GI motility Agent (bethanechol/metoclopramide)Phase V – combo (H2 or PPI) + BTH/MET
23Peptic Ulcer DiseaseA peptic ulcer is erosion in the lining of the duodenum.Causes: H. pylori infection, NSAID, Zollinger-Ellison syndrome, Smoking, StressClinical Features:Epigastric pain that is achyNausea, vomiting, weight loss, Upper GI bleed
24Diagnosis Endoscopy is most accurate test Histological evaluation of endoscope biopsy – Gold Standard for H. pylori infectionUrease Breath Test – Shows active infection, and efficacy of antibiotic therapySerum gastrin- specific test for ZE Syndrome
25TreatmentLifestyle mods(Reduce smoking,stress, ETOH, NSAID) No food before bedtime!If H. pylori is present use Triple or Quadruple therapyTriple ( PPI + 2 antibiotics)Quadruple (PPI + Peptobismol + 2 Antibiotics)
26Treatment H2 blockers help with ulcer healing Surgical intervention need for complications of PUD like bleeding, perforation
27Case StudyA 30 year old woman comes to the clinic complaining of chest pain. For the last 2 years, she has had intermittent nocturnal chest pain that lasts up to 10 minutes. The pain is substernal and radiates to her throat. It is 6/10 and wakes her up from sleeping. She has mild nausea and a clammy feeling. In the past, she has used antacids and PPI which did NOT help. Aerobic exercise sometimes instigates this pain.
28Case StudyShe reports being quite healthy except for having Raynauds phenomenon in winter and migraines treated with sumatriptan. Social history is remarkable for cocaine use. Vital signs and physical exam are unremarkable. Holter monitor study is arranged. What findings would be most likely evident during an episode of her chest pain?
29Case Study A) PR segment depression B) Normal electrocardiographic tracingC) Prolonged QT interval with increased duration at nightD) Transient St elevation in inferior Leads
30AnswerD) This patient has a classic presentation of Variant Angina, which is caused by coronary vasospasm that induces transient ischemia and ST elevations. Patients are usually young women w/o classic CVS risk factors. It usually occurs at night and can be worsened by cocaine and serotonergic agents like sumatriptan.
31AnswerVasospams can occur in any distribution but tend to favor the right coronary artery which supplies the inferior portion of the heartA = Pr depression is indicative of pericardits. Viral infection in Hx would have been a clue and leaning forward in bed would have produced relief.
32AnswerB= ST elevations and T wave changes are associated with variant angina. EKG can not be normalC= There is no reason to suspect QT interval prolongation. Pts who have syncopal episodes may have QT prolongation and it would not worsen at night.