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What classification is an angina patient (by the canadian classification) who gets chest pain walking up a flight of stairs?
What test would you do in moderately healthy male patient with exertional angina?
What do you use pre-test probability for?
To decide if this chest pain may represent cardiac chest pain. If you have a patient with an intermediate pretest score this would be the best patient to stress test
What are the 3 factors that help you decide the pretest probability that your patient's angina is acutally cardiac related?
Pain gender and type of gender
Why is an exercise stress test better than a nuclear stress test?
Exercise tests gives us a better look at functional capacity
What is a contraindication to running an EKG stress test? (focus on the EKG reasons)
- Wolf-parkinson white
- ventricular paced rhythm
- Resting ST wave changes more than 1mm
- (abnomal base EKG)
Who gets better benefit out of an echo than a nuclear stress test
- all structural heart defects
- congenital defect
- shunting defect
- Younger Females
Who gets the better benefit out of a nuclear stress test?
People with prior Ischemic heart disease particularlly MI
Who can't you do an exercise stress test on b/c of the exercise?
- Stroke patients
- Elderly (especially osteoarthritis)
What are some drugs you can use to induce a chemical stress test?
- Adenosine (especially during nuclear stress test)
- Dobutamine to increase the MV02
Does ichemia on an ECG corrolate to the coronary artery that is diseased?
No only infarction does
What two leads do you monitor during a treadmill test?
V4 and V5
What treatment options do you have for a patient with chronic stable angina that is found to be at intermediate risk after their stress ECG?
- Medical management and catheterization
- Low risk patients do better with medical management
- High risk patients have better outcome with catheterization PCI
What is the best statin to discharge a patient on who has just had a PCI?
atorvastatin simvustatin (high end statins they have severe disease)
What is the first line drug for acute exacerbations of chronic stable angina?
What is the first line drug for normal baseline angina in a patient with chronic stable angina?
Beta blockers (followed by calcium channel blockers)
Why do you need to be careful if you combine Beta-Blockers and Calcium channel blockers when treating chronic stable angina?
3rd Degree AV block and Severe Bradycardia
What is the full medical management plan for a patient with Chronic stable angina? (our patient in class was just being discharged from a PCI procedure for a LAD 80% blockage)
- Vascularprotective medications
- ACE inhibitors
- Chest pain treatments
- first line is Beta-Blockers if they cant do that then a calcium channel blocker
- if the beta-Blockers is not managing the pain then do both BB and CCB
- If neither works then last line is Long acting nitro (bad b/c of tolerence)
- If still have chest pain then PCI again or CABG
Do you ever do CABG without a previous PCI?
NO cath first to determine level of disease
47 year old female who complains of chest pain of the last 4 days chest pressure radiating to left arm. First episodes about 25 mins before resolving. All episodes occurred at rest. The last attack started 3 hours ago and lasted 70 mins. She has a past medical history of Diabetes, hypertension and cholithiasis. Meds for diabetic and hypertension meds non-smoker non drinker. EKG has sinus tachycardia with no ishemic changes and was performed while she was at rest with no pain. JVD is normal no murmurs rubs or gallops, no edema no clubbing etc. What does the patient have?
Chronic stable angina
What are 3 factors that differenting between Unstable angina and stable angina?
length of time, crescendo, came on at rest, (also first episode)
What is the deciding factor that differentiates between NSTEMI and unstable angina
Cardiac enzyme elevations and EKG changes
What do you have to do to rule out an MI in an unstable angina patient?
- At least two cardiac enzyme sets
- Multiple EKGs every 30mins
Which is more significant for MI right or left arm pain?
Do you give Fibrinolytics to an NSTEMI?
What do you give to every patient admitted with chest pain?
Asprin (or plavix if they are allergic to asprin)
What do you give a patient with NSTEMI?
- Heparin and asprin
- Morphine possibly oxygen
Who gets integrillin?
- People who have NSTEMI not getting cathed
- all pts getting catheterization
How do you treat an NSTEMI?
- Heparin, integrillin, admission, MONA
- possibly catheterization
What are the treatment criteria for giving a patient with chest pain fibrinolytics (when do you give fibrinolytics?)
- with: greater than 2 mm ST elevation or 1mm in limb lead in two contiguous leads with signs and symptoms of cardiac ischemia or a new onset LBBB
What are contraindications for using fibrinolytics?
Intercranial hemorrhages, prolonged CPR, pregnancy, recent trauma or surgery, elevated bloodpressure 220/110 etc
What is door to drug time for fibrinolytics?
what is door to cath time for a patient?
At what time after onset of chest pain can you no longer cath or fibrinolyse?
Pain present for more than 12 hours
If you have triple vessel disease what procedure do you get?
What would you do for a patient with an NSTEMI who has a low BP and pulse of 58?
Normal saline and asprin, NO NITRO, NO BETA BLOCKERS
What do you treat a right sided STEMI with?
They persent Hypotension and Bradycardic so don't treat with MONA treat with fluids and aspirin
What is the cutoff for BNP?
100 anything above that is heart failure
when do you get a new echo in any patient with a valve disorder?
Every time there is a change in the murmur
what is the test of choice for all vavular disorders?
when atria dialates over 5cm what is the patient at risk for developing?
Who needs prophylaxis for Dental procedures?
Prosthetic valve, heart transplant, infective endocarditis, non-repaired congenital heart disease, with lasting effects or 6 wks after repair of congenital heart disease
What do you treat infective endocarditis with?
- PCN or ampicillin, or nafcillin with gentamycin with oxacillin
- (Pen, Ox, Gen)
If you are worried about MRSA in infective carditis patients then what antibiotic do you give them?
In a patient with infective endocarditis who is on coumadin therapy do you d/c their anticoagulation therapy?
Do you start coumadin for a patient with infective endocarditis?
What is the main finding in a child that would lead you to look for a VSD?
Failure to thrive, CHF symptoms
Machinery-like murmur that radiates to left clavical
Wide fixed splitting of S2
What do you treat PSVT with?
- Adenosine/vagal maneuvers short term
- Beta blockers long term
Can you fix a patient with aortic stenosis pharmacologically?
No surgery is the only option
A patient has a non weeping ulcer on their lower left limb with some pain walking what vascular disorder?
Arterial not bleeding not pussing = arterial are dry venous are wet note: claudication is also an indicator
if you suspect PAD what diagnostic studies should you get?
Ankle brachial index, listen for bruits in aorta and renal arteries
What size would you correct a AAA ?
Acute sever pain in lower left leg, pulse can not be located by