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Which of the following is the most important measure for the prevention of coronary artery disease?

  • Diet modification
  • Regular exercise
  • Control of hypertension
  • Cessation of smoking (correct)

    • Beta blockers are considered a primary treatment for variant angina.

    False

    What is the most common type of myocardial infarction?

    Anterior MI

    In myocardial infarction, cardiac pain lasts longer than ___ minutes.

    <p>20</p> Signup and view all the answers

    Which of the following cardiac markers is the most sensitive for detecting myocardial infarction?

    <p>Troponin</p> Signup and view all the answers

    Match the types of myocardial infarction with their characteristics:

    <p>Anterior MI = ST elevation in leads V1 to V4 Lateral MI = ST elevation in leads V5, V6, aVL, and lead I Inferior MI = ST elevation in leads II, III, and aVF Posterior MI = ST elevation from V1 to V6 including V7, V8, V9</p> Signup and view all the answers

    In unstable angina, there is ST elevation and elevated cardiac markers.

    <p>False</p> Signup and view all the answers

    List one drug class used for the symptomatic treatment of angina.

    <p>Beta blockers</p> Signup and view all the answers

    What does CK-MB primarily help to detect in a patient who may have experienced a myocardial infarction?

    <p>Re-infarction</p> Signup and view all the answers

    MONA refers to the immediate treatment of Morphine, Oxygen, Nitrates, and Aspirin in acute coronary syndrome.

    <p>True</p> Signup and view all the answers

    What is the main difference between PCI and thrombolytic therapy for STEMI?

    <p>PCI is always superior to thrombolytic therapy.</p> Signup and view all the answers

    The ideal time for reperfusion therapy through PCI is within __________ minutes.

    <p>90</p> Signup and view all the answers

    Which of the following is NOT a contraindication for thrombolytic therapy?

    <p>Active infection</p> Signup and view all the answers

    Match the following types of myocardial infarction with their corresponding treatment:

    <p>ST elevation (STEMI) = Reperfusion therapy (PCI or thrombolytics) No ST elevation (NSTEMI or unstable angina) = MONA followed by heparin Re-infarction = CK-MB testing Acute pericarditis = Anti-inflammatory treatment</p> Signup and view all the answers

    Name one of the first-line discharge medications for all types of acute coronary syndrome.

    <p>Aspirin</p> Signup and view all the answers

    Ventricular fibrillation is considered one of the most dangerous arrhythmias after acute coronary syndrome.

    <p>True</p> Signup and view all the answers

    Which of the following cardiac markers is commonly increased in myocardial infarction?

    <p>Troponin</p> Signup and view all the answers

    Diphtheria is a viral cause of heart failure.

    <p>False</p> Signup and view all the answers

    What is the primary treatment approach for patients with stable angina?

    <p>Immediate treatment with rest or sublingual nitrates.</p> Signup and view all the answers

    In acute coronary syndrome, the presence of ______ is characterized by central, crushing pain radiating to the jaw or left arm.

    <p>cardiac pain</p> Signup and view all the answers

    What is typical cardiac pain characterized by?

    <p>Central, crushing, and radiating</p> Signup and view all the answers

    Match the types of myocardial infarction with their definitions:

    <p>ST segment elevation myocardial infarction = Characterized by persistent ST elevation on an ECG Non ST segment elevation myocardial infarction = Characterized by the absence of ST elevation, often with other ischemic changes Unstable angina = Chest pain due to reduced blood flow, not resulting in permanent damage Sudden cardiac death = Unexpected death due to cardiac causes, often from arrhythmias</p> Signup and view all the answers

    If a patient has atypical cardiac pain and a known history of CAD, functional studies are required before starting treatment.

    <p>False</p> Signup and view all the answers

    Cardiac pain often gets aggravated by ______, stress, emotions, and cold.

    <p>exercise</p> Signup and view all the answers

    Study Notes

    Cardiovascular Risk

    • Cardiovascular risk < 10% may indicate another diagnosis.

    Stable Angina

    • Cardiac pain lasting up to 15 minutes, relieved by rest or sublingual nitrates.
    • Patients with known history of CAD and typical cardiac pain should start treatment immediately without investigation.
    • Patients with known history of CAD and atypical cardiac pain require functional studies such as Exercise Echo, Thallium scan, or Exercise ECG.
    • Patients with no history of CAD require cardiovascular risk assessment:
      • Risk > 90%: immediate treatment.
      • Risk 90-61%: angiography.
      • Risk 60-30%: functional studies.
      • Risk 29-10%: calcium CT score.
    • Male patients older than 70 years should start treatment immediately.
    • Female patients older than 70 years should undergo angiography.

    Management of Stable Angina (Long Term)

    • Lifestyle modification:
      • Diet
      • Exercise
      • Quitting bad habits
      • Control risk factors (diabetes, hypertension, hyperlipidemia)
    • Symptomatic medications (monotherapy):
      • Sublingual nitrate (GTN):
        • Sublingual at home or as a spray
        • Given when symptoms occur or as prophylaxis
    • If monotherapy is not enough:
      • Add calcium channel blockers (CCB)
    • Invasive procedures:
      • Percutaneous Coronary Intervention (PCI)
      • Coronary Artery Bypass Grafting (CABG)

    Variant (Prinzmetal) Angina

    • Caused by sudden spasm of a coronary artery.
    • Patients are typically female, experiencing angina at night (at rest).
    • ECG shows ST elevation.
    • Management: Calcium Channel Blockers (CCBs).
    • Contraindicated medications:
      • Aspirin
      • Beta blockers (can cause coronary artery spasm)

    Acute Coronary Syndrome (ACS)

    • Includes:
      • Unstable angina
      • Non ST segment elevation myocardial infarction (NSTEMI)
      • ST segment elevation myocardial infarction (STEMI)
    • Cardiac pain lasting more than 20 minutes in MI.
    • Myocardial cell death in MI leads to the release of cardiac enzymes into the plasma.
    • Differentiation:
      • Unstable angina: No ST elevation, no cardiac markers.
      • NSTEMI: No ST elevation, elevated cardiac markers.
      • STEMI: ST elevation, elevated cardiac markers.

    Myocardial Infarction (MI)

    • Types of STEMI:
      • Anterior MI: Blockage in the left anterior descending artery (most common).
        • ECG changes: ST elevation in chest leads from V1 to V4.
      • Lateral MI: Blockage in the left circumflex artery.
        • ECG changes: ST elevation in the lateral leads (V5, V6, aVL, and lead I).
      • Inferior MI: Blockage in the right coronary artery.
        • ECG changes: ST elevation in aVF, lead II, and lead III.
        • Right coronary artery supplies the heart's conductive system (AV node and SA node), which can lead to heart failure with bradycardia.
      • Posterior MI: ST elevation from V1 to V6 in addition to V7, V8, and V9 (back leads).

    Cardiac Markers

    • Myoglobin: Rises first.
    • Troponin: Most sensitive, drops in 7 to 10 days.
    • CK-MB: Used to detect re-infarction as it drops rapidly (in 3 to 5 days).

    Management of Acute Coronary Syndrome

    • Give MONA to all patients:
      • Morphine
      • Oxygen
      • Nitrates
      • Aspirin
    • Then do serial ECG and cardiac markers:
      • If ST elevation (STEMI):
        • After MONA, do reperfusion therapy:
          • PCI: Superior to thrombolytic therapy, ideal time is 90 minutes.
          • Thrombolytic therapy (by streptokinase or tPA): Optimal time is 30 minutes.
    • If no ST elevation (NSTEMI or unstable angina):
      • After MONA, give heparin.
      • Assess cardiovascular risk (GRACE score).
      • High risk GRACE score:
        • Give glycoprotein II B/III A inhibitor.
        • Do angiography within 4 hours.
    • Discharge medications:
      • Aspirin for life.
      • Beta blockers for life.
      • ACEI for life.
      • Statin for life.
      • Clopidogrel:
        • STEMI: 1 month.
        • NSTEMI or unstable angina (GRACE score > 1.5%): 1 year.

    Complications of ACS

    • Cardiogenic shock: Treat like heart failure.
    • Arrhythmias:
      • Most common: Bigeminal (dangerous) and trigeminal.
      • Most fatal: Ventricular fibrillation.
      • AV block in anterior MI is dangerous and needs a pacemaker.
    • Pericarditis:
      • Early: Caused by spread of inflammation from the heart to the pericardium.
      • Late (Dressler's syndrome): Occurs 1 to 3 weeks after MI, caused by antigen-induced inflammatory response.

    Cessation of Smoking

    • Most important measure for preventing coronary artery disease.

    Note:

    • Streptokinase is used once in a lifetime.
    • CABG is used once in a lifetime.
    • In stroke reperfusion therapy, streptokinase is not used; only tPA is used.

    Contraindications to Thrombolytic Therapy:

    • Hemorrhagic stroke ever.
    • Ischemic stroke within the past 6 months.
    • Upper GI bleeding within the past month.
    • Major trauma or surgery within the past 3 weeks.
    • Pregnancy.
    • CNS tumors (highly vascular).

    Ischemic Heart Diseases (IHD)

    • Clinical presentation: Cardiac pain.
    • Causes:
      • Decreased blood supply to the heart
      • Increased demands
      • Decreased oxygen-carrying capacity of blood.
    • Types:
      • Stable angina.
      • Variant angina.
      • Acute Coronary Syndrome (ACS):
        • Unstable angina.
        • NSTEMI
        • STEMI
        • Sudden cardiac death (SCD)

    Criteria for Cardiac Pain:

    • Central, crushing, radiating to jaw or left arm.
    • Aggravated by exercise, stress, emotions, and cold.
    • Relieved by rest or sublingual nitrates.
    • Typical cardiac pain: all 3 criteria present.
    • Atypical cardiac pain: 2 criteria present.
    • Non-cardiac pain: 1 or less criteria present.

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