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