Dr. Schreiber's Review # 2This is a featured page


  1. Chest Pain - causes
    • Resp
    • Cardio
    • GI
    • Renal
  2. Aortic Dissection
    1. Causes?
      1. Atherosclerosis and with high BP
      2. Marfan's etc.
    1. Chest pain (C/P)
      1. Tearing
      2. Back
    1. O/E
      1. Check for BP in 2 arms!
      2. Check for both femoral pulses
      3. Branch occlusion
        1. MI
        2. Stroke
        3. Renal
      1. If tears:
        1. Tamponade
        2. Pleural effusion
    1. Workup
      1. CXR
        1. Widened mediastinum
        2. CT angiogram (can actually see the dissection)
        3. TEE (trans-esophageal echocardiogram)
      1. Two types:
        1. Type A: proximal to the left subclavian
        2. Type B: only distal
      1. Management:
        1. Type A: Control BP + surgery
        2. Type B: Control BP
        3. REMEMBER YOU DON'T WANT TO THROMBOLYZE SOMEONE WHO'S HAD AN AORTIC DISSECTION
  3. Coronary Disease
    1. Risk factors
      1. AGE! Biggest risk factor!
      2. Male
      3. Smoking (and other framingham criteria)
      4. Systolic BP
      5. Diabetes
      6. Dyslipidemia
      7. Total Cholesterol
      8. FHx (of premature disease)
  4. Stable AP (angina pectoris)
    • Predictable; always the same (eg. Whenever I run with the dog, etc.
    • Consistent pattern of typical chest pain, described usually with which adjectives?
      • Tightness
      • Heaviness
      • Squeezing
      • Pressure
  5. Elements of coronary disease causing angina (categories of factors in will address in management);
    1. Risk factor management
      1. Weight loss
      2. Lifestyle
      3. Diet
      4. BP control
      5. Exercise
    1. Syptom Relief
      1. nitroglycerine (NTG)
    1. Prevent complications
      1. ASA
      2. ACEi
    1. Prevent episodes of angina
      1. Beta blockers (1st choice)
      2. CCBs
      3. Nitroglycerine (NTG) (used to give much longer
  6. What about UNSTABLE ANGINA? Four ways that someone with ischemic type chest pain make you worry?
    1. Pain at REST!
    2. Worsening pattern
    3. New onset - would imply that everyone who has angina pectoris may be at risk for this; foirst few episodes not sure what the pattern is but more pertinent to patient who's experienced pain/tightness for a while then comes in with changed pattern
    4. Right after an MI
  7. 2 types of MI (3 ways to categorize)
    1. STEMI vs. NSTEMI
      Q wave vs. Non-Q wave
      Transmural vs. Subendocardial
    • To diagnose an MI, according to WHO, need 2 out of 3 of…
      1. Biochemical markers
        1. CKMB
          • creatine kinase an Mg2+-activated enzyme of the transferase class that catalyzes the phosphorylation of creatine by ATP to form phosphocreatine. The reaction effectively stores the energy of ATP as phosphocreatine in muscle and brain tissue and holds the muscle concentration of ATP nearly constant during the initiation of exercise. It occurs as three isoenzymes, each having two components composed of M (muscle) and of B (brain) subunits. CK1 (BB) is found primarily in brain, CK2 (MB) primarily in cardiac muscle, and CK3 (MM) primarily in skeletal muscle. Differential determination of isoenzymes is useful for clinical diagnoses.
        1. Troponin I and/or Troponin T (depedning on labs)
      1. Chest pain
      2. ECG changes
        1. ST elevation
        2. Q waves
  8. Acute Coronary Syndrome
    1. STEMI
    2. Non-STEMI
      • Have to wait a while then do biochemical markers (CKMB/Troponin)
    1. When see Q waves evolve?
      • 12-24 hours (though will also stay for months later)
  9. Treatment of ACS
    1. 1st thing: ABC's
      • Really does matter: some people need to be intubated right away or going into coma so before chewing an aspiring, want put on some oxygen, etc.
    1. Oxygen
    2. i.v.
    3. Monitor (ECG)
      • Can develop an arrhythmia very quickly; you want to be able to intervene promptly; ECG isn't to diagnose MI or not but they're at high risk for sudden arrhythmia so put immediately on ECG monitor
    1. Analgesia - not just for pain control but limiting size of infarct by limiting oxygen demand
      • NTG (as long as don't drop BP; NTG will drop venous tone, and to a lesser extent arterial tone)
        • May need to give NTG i.v.
      • Morphine
        • I.V.
    1. ASA - 2 tablets to chew so have limited platelet activity
    2. Beta blocker
      • Have to ask yourself, if have wheezing, uncontrolled asthma, arrythmia which wouldn't want give beta-blocker to them (heart failure or bradycardic)
    • So we've attacked demand so far, but what about increasing supply? (see italicized factors)…other drug we give to increase supply?
    1. Heparin!
    2. If ST elevation in 2 leads, , 12 hours of back pain, no contraindication, then ADD (in addition to Heparin):
      1. Thrombolysis
        1. Streptokinase
        2. tPA
        3. Some patients GPIIbIIIa platelet antagonists
    1. Angioplasty
  10. Contraindications to tPA etc.
    • Active bleeding
    • Hemorrhagic stroke (if ever had this)
    • Aortic dissection
    • Ischemic stroke (within about 1 yr)
    • Any CNS issue (eg. Relatively recent neurosurgery, a brain tumor, etc)
    • Recent surgery
    • (also have long list of relative contraindications but the ones above are absolute ones)
  11. Complications of MI
    1. Arrythmia
      1. Too slow
        • Can get any degree of heart block and sinus bradycardia
      1. Too fast
        • Two broad categories:
          • Supraventricular
            • A fib.
            • A flutter
            • Paroxymal Atrial Tachycardia (PAT)
          • Ventricular
    1. Other
      1. Pump dysfunction
        1. CHF
        2. (if gets REALLY BAD): Cardiogenic shock
      1. Rupture
        1. VSD
        2. Tamponade
        3. (Papillary muscles rupture): MR (Mitral valve regurgitation)
      1. Pericarditis
      2. Endocardial involvement leading to mural thrombus (not that big a problem unless it embolizes though)
  12. Stress test
    1. 'Stressors'
      1. Exercise
      2. Dobutamine (like dopamine; makes heart beat faster; can provoke ischemia)
      3. Dipyridamole (antiplatelet and arterial dilator; 'steals blood')
    1. 'Detectors'
      1. Symptoms
      2. BP, HR
      3. ECG, ST ↓
      4. Nuclear
        1. Perfusion (Sestamibi, aka Cardiolite)
        2. Thallium
      1. Stress Echo
  13. Revascularize
    1. PTCA + stent
    2. ACB (aortocoronary bypass)
  14. CHF:
    1. Symptoms/Signs
      1. Forward - fatigue
      2. Backward - congestion
        1. Dyspnea/orthopnea/PND (paroxysmal nocturnal dyspnea)
        2. SOA (swelling of ankles) (particularly at end of day)
        3. May or may not get right upper quadrant tenderness (may have distension of liver with ascites)
      1. Let's focus on left heart failure: causes
        1. Underlying (4 major causes):
          1. CAD (Coronary Artery Disease) - MI
          2. ↑ BP (Hypertension)
          3. Valvular
          4. Cardiomyopathy (usually 3 different kinds: hypertrophic (ventricle enlarges without aortic stenosis or hypertension); restrictive (Ventircle inflitrates with sarcoid, hemochromatosis or amyloid) more comon idiopathic kdilated cardiomyopathy have had chronic alchohol exces, have prost partum form, etc)

    1. Precipitating
      1. Increased demand
        1. Fever/Infection
        2. Anemia
        3. Pregnancy
        4. Thyrotoxicosis (↑ T4)
      1. New heart problem
        1. Acute ischemia
          • Person with stable angina with poor LV function because of prior MI
        1. Arrythmia
          • Remember heart needs time to fill and empty; in this case lose diastolic filling and blood tends to back up in heart
          • Endocarditis
        1. Non-Adherent/Drug
          • Extra salt in diet
          • Stop diuretics
          • NSAID (salt retaining)
          • Transfusion
          • Suddenly put on beta-blocker (which reduces contractility)
    • Idea here is: you may have underlying cause of heart disease but then the issue to ask is: why are you sick RIGHT NOW? Why sick today?
  15. Treatment
    1. Acute
      1. L - Lasix (furosemide)
      2. M - Morphine (these pt's very anxious; vasoconstricted, harder for heart to empty)
      3. N - Nitroglycerine (dilates veins)
      4. O - Oxygen
      5. P - Position (they're really sick but let them sit up; it's OK!)
    1. Chronic
      1. Diet - ↓ Na
      2. Diuretics
      3. ACEi
      4. Beta-blockers
      5. + spironolactone
      • 3,4,5 improve prognosis; 1,2 are for symptoms
      • + digoxin!
  16. Beta-blockers cause acute pulmonary edema; how give to people with CHF? If get someone with pulmonary edema stabilized, start bb on low dose, then can slowly titrate up and should be ok; something that the cardiologist does once the patient has been discharged


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alio34 		Latest page update: made by alio34 , May 25 2008, 11:44 PM EDT (about this update About This Update alio34 Edited by alio34

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