CAD High plasma LDL ( > 100 ) Risk Low plasma HDL ( < 40 ) factors DM Hypertension, Smoker, couch potato Family hx of heart disease <age 55; female <65 BEWARE OF Vasculopaths
THE BIG ONE Provoking: Emotion or exertion Quality: Heaviness, squeezing, pressure, smothering, crushing Radiation : L arm, R arm, jaw, neck, back Relieved : By rest Severity: Quiet patient with a 10/10 pain Time : Variable
3 high risk patients: Diabetics, females and elderly 20 % with proven mi have only upper abd pain 40% pain radiates to right side Atypical Character: 1/3 pressure, but others sharp stab Presentations aching or indigestion Common only 1/3 with exertion JAMA. 2005 Nov 23;294(20):2623-9
Nausea, vomiting, diaphoresis Fatigue (Levine’s) sign, dyspnea CAD Unstable angina vs stable Signs & Gut instinct Symptoms
Usually > 30 minutes Worrisome If lasts > 15 minutes despite 2 nitroglycerin SL separated by 5 minutes, suspect MI May present as sudden onset SOB due to CHF
Quiet, still, diaphoretic patients ¼ of patients with anterior M.I. have ↑ HR and/or HTN S4, S3, signs of CHF New murmur (Mitral regurgitation – in systole) Physical EXAM PAD Denial “I feel like I am going to die.”
Obvious MI
Previous EKG!! One EKG begets another ~50% of people normal repolarization abnormalities EKG T wave or ST segment changes (depressed, elevated, flipped) NSSTW New BBB
ST segment elevation WITH reciprocal ST segment depression OR new LBBB
Stages of MI First: T wave flips in early ischemia. Then: ST elevation either flat or tombstoning Finally: We see Q waves.
Where is the MI
The EKG is a snapshot.
63 y/o male : Chest pain – EMS responds…
“ My pain is getting worse…”
“I really don’t feel so well…”
50 y/o male with “indigestion”
T wave inversion can be seen as the sole ECG change in 10% of AMI.
58 y/o female with chest pain Deep anterior T waves are consistent with LAD (left anterior descending) disease and represent a high-risk group
Her cath report Lesion on mid LAD 99% stenosis
Post hospital clinic visit
BB ACEI Statin ASA/Antiplatelet The Cardiology “Happy Meal” “I feel dizzy now” “I don’t want to be on all these medications” Phase II Cardiac Rehab
42 y/o male presented with intermittent chest pain. Case HX: HTN, smoking, hyperlipidemia severe, possible ehlers danlos. High stress lifestyle. Worked as a mechanic. Thin framed.
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