Unstable Angina/NSTEMI
Unstable angina and NSTEMI is acute / new onset exertional chest pain that can occur even at rest. What differentiates NSTEMI from Unstable angina?
-NSTEMI has elevated troponin at time of diagnosis.
-NSTEMI always warrants consultation to Cardiology. If troponins are significantly elevated, patients need heart catheterization.
Patients presenting with STEMI should receive what (3) medications prior to PCI?
-Aspirin
-Anticoagulant Therapy (Heparin)
-P2Y12 inhibitor (Clopidogrel, Prasugrel, Ticagrelor). Only Clopidogrel if patient is to receive thrombolytic therapy.
Also:
-High-intensity statin to lower LDL>50% sent (Atorvastatin 40, Rosuvastatin 20)
-Beta-Blocker initiated within 24 hours of presentation
-ACEi initiated within 24 hours of presentation if impaired LV function, HF, or anterior wall infarction
In the context of heart failure, how does volume overload usually clinically present?
-Crackles on lung auscultation
-Jugular venous distention
-Peripheral edema
-Exertional dyspnea
-Orthopnea
-Nocturnal dyspnea
What are 2 common causes of heart failure with preserved ejection fraction?
-Hypertension
-Aging
-Coronary artery disease
-Obesity
-Diabetes
If you get hungry on nights and there is no food left in the cubby, where do you go?
Surgery Lounge (2nd Floor)
Patients with NSTEMI should undergo anticoagulation with intravenous unfractionated Heparin or subcutaneous Enoxaparin. Which would you recommend in a patient with kidney dysfunction?
-IV Heparin because enoxaparin is partially cleared by the kidneys.
-Anticoagulation should be provided until revascularization and is generally continued until discharge
When is thrombolytic therapy recommended for patients with STEMI?
-Symptom onset <12 hours
-PCI not available within 2 hours of first medical contact
-Can consider thrombolytic therapy if symptom onset 12-24 hours before presentation and there is hemodynamic instability or significant myocardium at risk (ex. Anterior MI)
-After administration, EKG should be performed at 60 and 90 minutes to confirm at least 50% improvement in maximal ST-elevation. There is high chance of thrombolytic failure, so patients should be transferred to a PCI-capable hospital and coronary angiography should be performed prior to discharge.
For patients with chronic symptomatic systolic heart failure, guidelines recommend replacing an ACEi or ARB with ___ .
-Valsartan-Sacubitril (Entresto)
-Sacubitril is a neprilysin inhibitor. Inhibition prevents degradation of natriuretic peptides leading to enhanced diuresis.
What is the primary diagnostic test in the evaluation of heart failure?
-Echocardiography: Provides information regarding heart size, systolic/diastolic function, wall motion abnormalities and valvular disease.
Where can you purchase these solar-powered string lights, currently on sale for 29.99 (with 10 dollars off)?
Costco, East Lansing.
The TIMI Score can be useful in providing risk stratification to patients who present with unstable angina and NSTEMI.
What does it the TIMI Score predict?
TIMI Score predicts risk of 14-day death, recurrent MI, and urgent revascularization rates.
Age>65
>3 CAD risk factors (Hypertension, hypercholesterolemia, diabetes, FHx. CAD, current smoker)
Known CAD (> 50% stenosis)
Aspirin use in the past 7 days
>2 episodes of chest pain in last 24 hr
ST changes >0.5 mm
Elevated Troponin
Score 0-2: Low Risk
Score 3-4: Intermediate Risk
Score 5-7: High Risk
What are the hallmark EKG features of STEMI:
-ST-elevation of >1 mm in 2+ contiguous limb leads or chest leads, except V2 and V3 where ST elevation >2mm in men and >1.5 mm in women
-ST-elevation is measured in reference to the J-point.
-Contiguous leads are anatomically linked
-II, III, aVF = Inferior
-I, aVL, V5, V6 = Lateral
-V1-V4 = Anterior Septal
Arrhythmias are a common cause of death in patients with heart failure. Implantable cardioverter-defibrillators (ICD) improve survival. What criteria should be met prior to undergoing ICD implantation?
-Patients receiving guideline-directed medical therapy
-LVEF < 35%
-NYHA II or III
-NYHA IV only if patients are candidates for heart transplant or left-ventricular assist device (LVAD) placement
Severity of heart failure is categorized according to the New York Heart Association (NYHA) functional classification. What defines the 4 categories?
-NYHA I: No limitations of physical activity
-NYHA II: Mild limitations with physical activity
-NYHA III: Severe limitations with physical activity
-NYHA IV: Unable to carry out any physical activity without symptoms
In the Harry Potter movies, who did this wand originally belong to?
Lucius Malfoy
What is Ranolazine used for?
How does it work?
What factor can affect dosage?
-Ranolazine decreased symptoms of angina and modestly increases exercise times in patients with stable angina.
-It inhibits late sodium currents, preventing sodium overload in the cell and sodium-calcium exchange.
-Dosage should be decreased if used with medications that moderately inhibit cytochrome P450 (verapamil, diltiazem). Ranolazine should not be used in patients receiving strong inhibitors of cytochrome P450 (clarithromycin, itraconazole, ketoconazole, and some HIV medications).
STEMI involves plaque rupture and thrombosis, leading to acute coronary artery occlusion and infarct. However, several other conditions can mimic STEMI findings on EKG. Name 4 of them.
-Pericarditis: Try to distinguish if pain is pleuritic and positional. ST-elevation is usually diffuse.
-Myopericarditis: Viral and autoimmune conditions
-Accelerated hypertension/Left ventricular hypertrophy: ST-elevation are typically concave in appearance.
-Aortic Dissection: ST-elevation if dissection involves left or right coronary artery. Surgical emergency!
-Severe hypercalcemia: EKG may also shortened QT interval and flattened T-waves
-Takotsubo Cardiomyopathy: Heart catheterization will be negative.
-Cardiac Syndrom X: Microvascular dysfunction, frequent cause of chest pain in women.
-Coronary Vasospasm: Drugs (cocaine, methamphetamines, bromocriptine).
Diuretic therapy remains the principal treatment for patients with decompensated heart failure and fluid overload. The preferred route of diuretic administration is ___ and doses can be used up to ___ times the home dose at the risk of ___.
-Intravenous doses of diuretics can be used at 2.5 times the home dose at the risk of transient kidney injury.
-Oral dose Bumex = IV dose Bumex
-Oral dose Furosemide = ½ dose IV Furosemide (ie. 40 mg oral = 20 mg IV)
What medication(s) have been shown to reduce morbidity or mortality in patients with diastolic heart failure?
-No drug has been shown to reduce morbidity or mortality
-The effect of spironolactone is unclear and its use is not supported by current evidence
In the Marvel movies, who is worthy enough to lift the mighty Mjolnir?
Thor
Odin
Vision
Captain America
Hela (maybe)
A 55-year old woman with acute onset substernal chest pain at the gym that lasted 10 min and improved with rest. She presents to the hospital on hour after symptom onset, still in her gym clothes. She has hypertension and hyperlipidemia. Non-smoker. No history of CAD. Does not take aspirin. EKG demonstrates 0.5 mm ST-depression in leads V2-V3, which is changed from prior EKG. Troponin x 2 is within normal limits.
What is her TIMI Score and what would you recommend as a next step?
-TIMI Score 1: 5% risk of 14-day adverse outcome (death, MI, urgent revascularization).
-Likely does not need heart catheterization
-Would recommend Exercise Stress Testing
Place the following complications of myocardial infarction in the order they typically occur after STEMI.
Categories:
Conditions:
Bradyarrhthmia/Heart Block
Papillary Muscle Rupture/Mitral Regurgitation
Thrombus Formation
Ventricular Arrhythmias
Cardiogenic Shock
Post-Infarction Pericarditis/Dressler Syndrome
Ventricular Wall Rupture
-Ventricular Arrhythmias (Vtach/Vfib): Within 4-24 hours due to ischemia. Can be 48hr if due to scar formation.
-Bradyarrhythmias/Heart Block: Within 24 hours. Common for inferior MI. May resolve spontaneously.
-Cardiogenic Shock: Within 24-48 hours. Leading cause of death following MI.
-Papillary Muscle Rupture/Mitral Regurgitation: Within 3-7 days. Ischemia results in partial or complete rupture, leading to mitral regurgitation. May have pulmonary edema and systolic murmur.
-Thrombus Formation: Within 3-10 days. Due to decreased contractility. Risk of embolization (stroke).
-Ventricular Wall Rupture: Within 5-14 days. Associated with large infarcts. Rupture can lead to hemopericardium and tamponade. Emergent pericardiocentesis. Watch for Beck’s Triad: Hypotension, JVD and Muffled Heart Sounds.
-Dressler Syndrome: >14 days. Immune system attack on cardiac antigens present in necrosed tissues. EKG: Diffuse ST-elevation and PR-depression. Watch for pleuritic chest pain improved by leaning forward. Possible friction rub. Treat with NSAIDs and colchicine, possibly glucocorticoids.
What is digoxin’s mechanism of action and when is it typically used in systolic heart failure?
-Digoxin is a positive inotrope. It inhibits myocardial Na/K-ATPase pumps, thereby decreasing heart rate and increasing force of contraction.
-Digoxin is used in patients who have symptoms despite optimal therapy with ACEi and beta-blocker
-Digoxin can be used when patients have systolic heart failure and concomitant atrial fibrillation for rate control
-Dosed to achieve serum level < 1 mg/mL
Diastolic heart failure is associated with this arrhythmia ____ and is associated with ___ morbidity and mortality.
-Diastolic heart failure is associated with atrial fibrillation, identified at some time point in 2/3 of patients.
-The presence of atrial fibrillation is associated with increased morbidity and mortality and the goal should be restoration and maintenance of sinus rhythm.
What type of dog is this?
Basenji
From Central Africa, close relative of the wolf
Hypoallergenic and friendly