Internal Medicine Handout for PLE October 2023

Approach to Clinical Problem Solving

• A cardiac stress test is not necessary for a 20-year-old female with chest pain that is not triggered by exertion and not relieved by rest or nitroglycerin.
• A 60-year-old female with hypertension and smoking history, presenting with retrosternal chest pain precipitated by exertion and relieved by rest, should not undergo a treadmill stress test.
• The clinician must establish whether the pain satisfies the three criteria for typical anginal pain: retrosternal or substernal in location, precipitated by exertion, and relieved within minutes by rest or nitroglycerin.
• Consider other factors, such as age and risk factors, to determine the pretest probability for angina pectoris.

Diagnostic Reasoning

• There are two ways to make a diagnosis: pattern recognition and several steps in diagnostic reasoning.
• Gather information with a differential diagnosis in mind, and undertake several steps in diagnostic reasoning.
• Conceptualize the patient's objective problem with the greatest specificity one can achieve.
• Look for discriminating features to support or refute each potential diagnosis.

Cardiovascular Medicine

• The most likely diagnosis for a 60-year-old female with hypertension and smoking history, presenting with retrosternal chest pain precipitated by exertion and relieved by rest, is angina pectoris.
• In making the diagnosis of angina pectoris, the clinician must establish whether the pain satisfies the three criteria for typical anginal pain.

Critical Care Medicine

• The next best step depends on the clinical state of the patient, the potential severity of the disease, and the uncertainty of the diagnosis.
• If the patient is unstable, the next best step is almost always therapy.

Trauma and Tension Pneumothorax

• The most urgent next step for a patient with severe dyspnea and absent breath sounds on the left lung after a traumatic chest injury is immediate decompression by doing needling thoracentesis.

Acute Coronary Syndrome

• For a patient being considered to have an acute coronary syndrome, the next best step is to treat with Aspirin, as it decreases mortality in the face of an acute coronary event.

Ischemic Chest Pain

• Ischemic chest pain has a sudden onset, increasing intensity, and is provoked by an activity (e.g., exercise, extreme emotion).
• It may or may not respond to sublingual nitroglycerin.
• Non-ischemic chest pain is usually predictable, precipitated by meal intake (GI causes), and changes in position.

Subarachnoid Hemorrhage

• The best initial test for a patient with sudden severe headache and focal neurologic deficit is a non-contrast head CT scan.

• If the CT scan is negative, a lumbar puncture may be necessary.

• The hallmark of aneurysmal rupture is blood in the CSF, and xanthochromia is the gold standard for the diagnosis of SAH.### Colicky Meningitis

• Presents with radiation of pain to upper abdomen, shoulders, arms, and back

• Can also radiate to wrist, fingers, neck, and throat, but not upper jaw

• Empiric antibiotics should be loaded

Cardiovascular Medicine

• Ischemic Heart Disease (IHD) types:
  • Acute Coronary Syndrome
  • Chronic Coronary Syndrome
• Risk factors:
  • Hypertension
  • Diabetes
  • Dyslipidemia
  • Obesity
  • Physical inactivity
  • Family history of premature CAD

Anginal Equivalents

• Dyspnea
• Faintness
• Fatigue
• Exertional dyspnea (may be an indicator of IHD even when angina is absent or no evidence of CAD on ECG)
• Postprandial angina (caused by redistribution of coronary blood flow, a marker of severe CAD)

Stress Test

• Used to increase sensitivity of CAD detection beyond ECG
• Exercise stress test is the choice because it provides physiologic data such as exercise time and workload
• Pharmacologic stress test forms: Dobutamine, Adenosine, and Dipyridamole

Coronary Angiogram

• Visualizes vessels up to small arteries
• Lesions that can be treated by angioplasty are up to 200μm only

Indications for Coronary Angiogram

• Patients >45 years and females >55 years who are to undergo a cardiac operation
• Patients after myocardial infarction
• Patients with angina pectoris, regardless of severity, in whom noninvasive testing indicates a high risk of coronary events
• Patients in whom coronary spasm or another nonatherosclerotic cause of myocardial ischemia is suspected

Chronic Coronary Syndrome

• Clinical presentation: inducible chest pain relieved by rest
• Diagnosis: ECG / Stress Test
• Management:
  • Medical
  • High risk features: send for coronary angiogram
  • Definitive Management: Revascularization (PCI or CABG)

Medications

• Aspirin: 81-162mg/day, cyclooxygenase-1 inhibitor, IA level of evidence
• Clopidogrel: 75mg/day, P2Y12 inhibitor, IB level of evidence
• Statins: 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, IA level of evidence
• ACEi/ARB: RAAS blockers, IA level of evidence
• Beta blockers: reduce heart rate, contractility, atrioventricular conduction, and ectopic activity, IA level of evidence### Class of Medications for Acute Coronary Syndrome (ACS)
• Calcium Channel Blockers (CCBs):
  • Verapamil: 80-160mg 3x daily (immediate release), 120-480mg daily (slow release)
  • Diltiazem: 30-80mg 4x daily (immediate release), 120-320mg daily (slow release)
  • Contraindications: low heart rate, conduction disorder, sick sinus syndrome, CHF/low blood pressure, cardiogenic shock, severe aortic stenosis
• Dihydropyridine CCBs:
  • Amlodipine: 5-10mg OD
  • Felodipine: 5-10mg OD
  • Nifedipine: 30-90mg OD (immediate release), 30-180mg OD (slow release)
  • Contraindications: severe aortic stenosis, obstructive cardiomyopathy, cardiogenic shock
• Nitrates:
  • ISMN: 30-120mg OD
  • ISDN: 5mg SL prn
  • Contraindications: hypertrophic obstructive cardiomyopathy, low heart rate, heart rhythm disorder, allergy
• Ivabradine:
  • 5mg-7.5mg BID
  • Contraindications: allergy, severe hepatic disease, cardiogenic shock
• Nicorandil:
  • 10-40mg BID
  • Contraindications: allergy, severe hepatic disease
• Trimetazidine:
  • 35mg BID
  • Contraindications: Parkinson's disease, tremor and movement disorders

Indications for Coronary Artery Bypass Graft Surgery (CABG)

• Left main coronary artery disease
• 3 vessel disease + LVEF < 50% or diabetes
• 2 vessel disease that includes proximal left descending coronary artery

Management of Acute Coronary Syndrome (ACS)

• Patients with unacceptable level of angina despite optimal medical management should be considered for coronary revascularization
• Patients with single- or two-vessel disease with normal LV function and anatomically suitable lesions are advised to undergo PCI
• Heart Team decision-making process involving cardiologist, surgeon, patient, and relative

Classification of Myocardial Infarction

• Type 1: Spontaneous myocardial infarction
• Type 2: Myocardial infarction secondary to an ischemic imbalance
• Type 3: Myocardial infarction resulting in death
• Type 4a: Myocardial infarction related to percutaneous coronary intervention (PCI)
• Type 4b: Myocardial infarction related to stent thrombosis
• Type 5: Myocardial infarction related to coronary artery bypass grafting (CABG)

Diagnostic Procedure for ACS

• ECG: diagnostic procedure of choice to determine the direction of management
• Troponin: laboratory parameter to dictate the management of ACS