Coronary Artery Disease

* Atherosclerosis #1 cause

* Fatty streak formation: lipid deposition in white blood cells=1ststep

* Risk Factors:

* Diabetes

* Smoking

* Hyperlipidemia

* HTN

* Male

* Age (>45 men >55 women)

* Family Hx

Stable Angina

Check out the Stable Angina Picmonic!

* Chest pain

* Substernal

* Poorly localized

* Exertional

* Radiation to arm, teeth, lower jaw

* Typically 1-5 minutes, but less than 30 by definition

* Relieved with rest or nitroglycerin

* Levine’s sign

* Clenched fist over chest

* Dx:

* EKG: ST depression, but normal in 50%

* Stress Testing:

* EKG

* + ST depressions

* Echo

* Used in pts with baseline EKG abnormalities

* Helps localize ischemia

* Pharmacologic therapy used with exercise contraindicated

* Pharmacologic=dobutamine

* Increase force of heart contractions

* Increases O2 demand

* Myocardial Perfusion Imaging

* Localizes Ischemia

* Pharmacologic=adenosine or dipyridamole

* Vasodilate normal arteries

* CI: asthmatics

* Coronary Angiogram

* GOLD STANDARD

* Gold standards are usually the test that gives us a definitive picture.

* Defines anatomy=definitive diagnosis

* Tx:

* Statin Therapy

* Helps stabilize lipid plaques

* MI is typically caused from plaque rupture vs occlusion

* Nitrates

* Venodilator (increases supply)

* Caution with use of PDE-5 inhibitors (sildenafil)

* Used for acute pain

* Advised to go to ER if used 3 doses (Q 5min)

* B blockers

* Used for daily, chronic management

* Reduces demand (negative chronotrope/inotrope)

* CCB

* Non-dihydropyridines (verapamil/diltiazem)

* Decrease vasospasm (increase supply)

* Decreases heart rate & contractility (decreases demand)

* For those who B blockers are contraindicated

* ASA

* Doesn’t address supply/demand

* Helps with platelet aggregation to prevent ACS

Unstable Angina

* Chest pain>30 minutes

* Negative cardiac enzymes

NSTEMI

* Chest pain >30 minutes

* Positive cardiac enzymes

* 3 sets Q8hours

* Creatinine Kinase (muscle breakdown marker)

* Troponin (most sensitive & specific)

* Negative

* Unstable Angina

* Treatment for Unstable Angina & NSTEMI is the same

* MONA

* Bblockers

* Heparin

STEMI

* ST elevations greater than 1 mm

* 2 contiguous leads

* May have reciprocal changes in opposite leads

* New LBB is STEMI equivalent (Carrot in V1)

* Anterior=V1-V4

* Left Anterior Descending

* Lateral= I, aVL, V5,V6

* Circumflex

* Anterolateral=I, aVL, V4-V6

* Inferior= II, III, aVF

* Right coronary artery

* Posterior Wall=V1-V2

* ST DEPRESSIONS