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IHD Patho 2012_Student Version (2)

Variant angina potential mechanism for vasospasm

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Variant Angina Potential mechanism for vasospasm Hyperactive sympathetic nervous system Defect in handling of calcium in vascular smooth muscle Alteration in nitric oxide production Imbalance between endothelium derived relaxation and contracting factors
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Silent Myocardial Ischemia Ischemia is present, but anginal pain does NOT occur Patients typically have: Altered pain threshold Autonomic neuropathy Can occur in: Elderly Diabetics
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Differential Diagnosis Pericarditis Esophageal reflux / peptic ulcer disease Aortic dissection Pulmonary embolism Biliary disease Musculoskeletal disease
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Patient History Detailed history of chest pain Nature Precipitating factors Duration Radiation Response to rest/SL NTG Assess risk factors
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Spectrum of CHD
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Acute Coronary Syndrome Non-ST-Segment Elevation ACS NSTE ACS ST-Segment Elevation ACS STE ACS Unstable Angina UA Non-ST Segment Elevation Myocardial Infarction NSTEMI ST Segment Elevation Myocardial Infarction STE MI
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Acute Coronary Syndrome Results primarily from diminished myocardial blood flow secondary to completely occlusive or partially occlusive coronary artery thrombus Due to plaque rupture
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ACS Stable Angina versus Stable Angina versus ACS ACS
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Acute Coronary Syndrome NSTE ACS Thrombus produces incomplete occlusion of coronary lumen ECG changes ST-segment depression T-wave inversion No changes No Q waves Cardiac biomarkers NSTE MI (+) UA (-) STE MI Thrombus completely occludes coronary lumen ECG changes ST-segment elevation Q-waves may also develop Transmural necrosis Cardiac biomarkers (+)
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STE MI = Complete Coronary  Occlusion Photo adopted from: http://nursingcrib.com/nursing-notes-reviewer/coronary-artery-disease/
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Clinical Presentation of ACS Midline anterior anginal chest discomfort Quality and radiation similar to chronic stable angina Longer duration usually > 20 minutes Patients with UA present with: Angina at rest Severe, new-onset (< 2 mo) angina Angina increasing in frequency, duration, or intensity Patients with NSTE MI or STE MI usually have prolonged, more intense rest angina Often not relieved with sublingual nitroglycerin
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Accompanying Symptoms Dyspnea Weakness Diaphoresis N/V Some patients less likely to present with classic symptoms Elderly, women, patients with diabetes
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Accompanying Signs No signs are classic for ACS Patients may present with signs of acute heart failure Jugular venous distension Rales – (+) S 3 3 rd heart sound that is not normally present May also present with arrhythmias
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Diagnostic Tests Electrocardigram (ECG) Laboratory tests Cardiac biomarkers Coronary angiography “Cardiac catheterization” Echocardiography Stress testing
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Electrocardiogram (ECG) Photo adopted from: http://www.bem.fi/book/06/06.htm One cardiac cycle: sinoatrial (SA) node Bachmann’s bundle
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