HHP CAD

HPI

• Chest pain: PQRST

• UA: AMI without e/o myocardial necrosis; biomarkers negative; new-onset, crescendo, or at rest
• NSTEMI: AMI with e/o myocardial necrosis; biomarkers positive
• Prinzmetal: spasm; young, smoker; h/o migraine, reynaud; non-exertional

• High Risk factors:
  • accelerating tempo in preceding 48H;
  • ongoing rest angina >20min 
  • recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy
  • Sn/Sx of heart failure
• Intermediate risk:
  • > 20 min rest angina, now resolved
  • < 20 min rest angina relieved with NTG
• Low risk:
  • New onset or crescendo angina
  • Without prolonged rest pain

• Any recent GI Bleed? Greenfield filter? Pacemaker/ICD? Aortic Stenosis? Posterior/back pain, ie. dissection? e/o Cerebrovascular disease? Amaurosis fugax, face/limb weakness/clumsiness/numbness/sensory loss/ ataxia/vertigo

• Cardiac Risk Factors:
  • h/o CAD, DM (A1C, microalbumin), HTN, h/o TIA/CVA/DVT/PE, HPL, Fam Hx, Smoking Hx, Age>65; TIMI risk:
• Functional status:
  • Current status and recent changes
  • NYHA class
    • Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities.
    • Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion.
    • Class III: patients with marked limitation of activity; they are comfortable only at rest.
    • Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest
  • MET level

Medications: ASA? BB? ACEi? Or ARB? Statin?

Allergy: Iodine?

PE:

• High Risk factors
  • Pulmonary edema, rales, s3 (overt heart failure)
  • Worsening MR
  • Hypotension or Hemodynamic instability
    • 20% of all cardiogenic shock complications are found in NSTEMI; 5% of all NSTEMI have cardiogenic shock with mortality > 60%
  • Age > 75yo
  • Sustained V-tach
  • LVFn<40%

Impression:

• Labs: Recent Lipid (within 3 months), Cr
• ECG: High Risk: ST change > 0.05 mV (5mm)
  • STEMI = 0.1 mV (1mm)
  • ST-segment depression: typically UA or NSTEMI
  • ST-segment depression in 2 contiguous anterior precordial leads (V1, V2): posterior MI
  • New Onset LBBB: MI
  • Inverted T waves: typically UA/NSTEMI
  • Marked symmetrical precordial T-wave inversion (>0.2mV, 2mm): acute ischemia, particularly of LAD
  • Non-specific ST-segment (< 0.05mV or 0.5mm) and T-wave inversion (<2mm) are less diagnostically helpful
  • Established Q waves greater than 0.04 second are less helpful in diagnosing UA, but by suggesting prior MI, they indicate a high likelihood of significant CAD
  • Isolated Q waves in lead III: may be a normal finding
  • Normal ECG in a patient with chest pain:
    • 1% - 6% of such patients eventually are proven to have had an MI (by definition, NSTEMI), and
    • at least 4% will be found to have UA
• CXR
  • e/o HF?

• Previous/Current ECHO (EF -- high risk EF<40%, valvular abnormalities -- AS, RWMA, diastolic function)
• Previous Stress testing (areas/% infarct/ischemia)
• Previous angiography/CABG/PTCA/Stent

• TIMI score:
• TIMI index (predicts short-term mortality in STEMI, 30day to 1 year mortality in all ACS including UA/NSTEMI): heart rate x [age/10]squared) div by systolic pressure.

Plan:

• Triage:
  • High risk: ICU, Intermediate, Cardiology
  • Intermediate: Intermediate, Med/surg
• Immediate medications
  • ASA 325mg PO crushed/chewed
  • Heparin or Enoxaparin (1mg/kg SC bid +/- 30 mb IVB)
  • NTG 0.4mg SL q5min x 3
    • contraindication: SBP<90, HR<50, suspected RV infarct, viagra/cialis use
  • BB: metoprolol 5mg IV q5min x 3 then 25mg PO q6H;
    • Contraindications: HR<60, SBP<100, moderate/severe CHF, 2^nd or 3^rd degree heart block, severe bronchospasm
  • Morphine: if sx persist or CHF
  • Oxygen: SaO2>92%
  • Anxiolytic
  • Consider platelet GP IIb/IIIa inhibition
• If RV infarct: caution with nitrates, beta-blockers, diuretics

• Telemetry for duration of stay
• ECG q6H x 3
• CE q6H x 3
• If inferior AMI, RS ECG for V4R
• Lipid profile if not done within 3 mos
• Other labs: PT/PTT/INR; K; CBC

• If DM, adjust insulin and fluids while NPO; hold metformin day before and day of possible angiography
• If Cr>1.5, consider mucomyst, bicarb gtt
• If CKD; check GFR (<60 abnormal), microalbuminuria, albumin/cr ratio
• If Iodine allergy, predisone 50mg 4p, 11p, 6a; benadryl 50mg q6H, pepcid 20mg BID; start evening prior to cath

• Overall goals from outpatient perspective:
  • smoking: complete cessation
  • blood pressure: < 130/80 especially if CKD, DM
  • lipids: LDL <<< 100
  • if triglycerides > 500, treat with fibrate/niacin before LDL lowering agents
  • diet:
    • saturated fats < 7% of total calories
    • adding plant stanol/sterols (2g/day), fiber (>10g/day) to further decrease LDL
    • consider omega-3 fatty acids in the form of fish or capsules
  • physical activity
    • cardiac rehab
    • overall goals: 30-60min q day of moderate intensity aerobic workout (brisk walk) 5 days per week; optimal daily; increase daily lifestyle activities (walking break at work, gardening, household work)
    • encourage resistance training 2 days per week
  • weight
    • BMI 18.5 – 24.9 kg/m2
    • Waist: men < 40 inches (102 cm), women < 35 inches (89cm)