Cardiovascular Medicine Book

Circulatory Disorders

Electrocardiogram

Myocardial Infarction

Symptoms

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Angina PectorisAka: Angina, Myocardial Ischemia, Ischemic Heart Disease, Vasospastic Angina, Prinzmetal's Angina

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  1. See Also
    1. Angina Diagnosis
    2. Unstable Angina
  2. History
    1. Ask Exercise History
    2. How often do you take Nitroglycerin?
  3. Symptoms
    1. See Chest Pain
  4. Diagnosis
    1. See Angina Diagnosis
  5. Types: Angina
    1. Chronic Angina (Fixed Obstruction)
      1. Resting angina: 90% stenosis
      2. Pretreat higher endurance activities
        1. Take Nitroglycerin sublingual before activity
    2. Unstable Angina (Plaque rupture)
      1. Myocardial Infarction high risk
        1. Often occurs with 2 weeks of symptom onset
    3. Vasospastic Angina (Prinzmetal's Angina)
      1. Most arterial lesions are eccentric (75%)
        1. Considerable vasoactivity in most vessels
      2. Vasoconstriction occurs at lesion with Exercise
        1. Paradoxical: vasodilatation would be expected
        2. Occurs due to passive vasodilation down stream
        3. Prevention
          1. Beta-Blocker
          2. Calcium Channel Blocker (may act in similar way)
  6. Labs: Biomarkers of chronic disease
    1. NT-proBNP
      1. Confers >5 fold risk of mortality if increased
    2. hs-CRP
      1. Confers up to 1.3 risk of coronary disease
    3. References
      1. Ndrepepna (2005) Circulation 112:2102
  7. Management: Non-Pharmacologic
    1. Mental Stress confers Myocardial Ischemia risk
      1. Decreases Left Ventricular Ejection Fraction
      2. Doubles the risk of ischemic complications
    2. References
      1. Jiang (1996) JAMA 275:1651
  8. Management: Pharmacologic (Mechanisms of action)
    1. Protocol
      1. Pearls
        1. Stress test or angiography again if need >2 agents
      2. Options
        1. Sublingual Nitroglycerin prn and before Exercise
        2. Beta Blockers (preferred)
        3. Long acting nitroglcerin
        4. Calcium Channel Blocker (third-line)
    2. Nitroglycerin
      1. Effects
        1. Reduces Preload
        2. Reduces afterload
        3. Dilates collaterals
    3. Beta Blocker
      1. Reduces Heart Rate
      2. Reduces afterload
      3. Decreases cardiac contractility
      4. Contraindications
        1. Decompensated Congestive Heart Failure (CHF)
    4. Calcium Channel Blocker
      1. Reduces afterload
      2. Prevents vasoconstriction
        1. No significant effect on vasodilatation
    5. Aspirin
      1. Platelet aggregation
    6. Combination: Beta Blocker with:
      1. Dihydropyridine Calcium Channel Blocker OR
      2. Nitroglycerin
    7. Ranolazine
      1. Used in combination with other agents above
      2. Reduces angina frequency and Nitroglycerin use
      3. Chaitman (2004) JAMA 291:309
    8. Lipid lowering agents
      1. Decrease morbid events significantly
        1. Myocardial Infarction
        2. Angina
      2. Do not significantly affect coronary lesions size
      3. Do probably change composition of Plaques
        1. Decreases risk of Plaque rupture
  9. Management: Comorbidity
    1. Major Depression
    2. Obstructive Sleep Apnea
    3. Obesity
    4. Cerebrovascular Disease symptoms
    5. Peripheral Vascular Disease
  10. Instructions
    1. Rehearse what to do:
      1. Severe Chest Pain
      2. Transient Ischemic Attacks
    2. Review Prevention
      1. See Cardiac Risk Reduction
      2. Omega-3-fatty acids
      3. Increase activity
    3. Testing (review if current, esp. if high risk)
      1. Stress Testing every 3-5 years
      2. CAD Biomarkers (see above) every 3-5 years
      3. Secondary prevention labs
        1. Lipid profile
        2. Hemoglobin A1C
    4. Review Goals
      1. Blood Pressure <130/80
      2. LDL Cholesterol <70-100 mg/dl
      3. HDL Cholesterol >45 mg/dl
      4. Body Mass Index optimization
      5. Hemoglobin A1C < 7.0
    5. Review Medications
      1. Aspirin
      2. ACE Inhibitor
      3. Beta Blocker
      4. Antianginals
    6. Follow-up
      1. Primary care visits every 6 months if stable
      2. Cardiology every 1-2 years
    7. Handouts
      1. Updated medication list and after visit summary
      2. Mediterranean Diet
  11. Documentation
    1. Problem Summary
      1. History of Myocardial Infarction
      2. Ejection Fraction
      3. Revascularization procedures
      4. Angina (stability, severity, ischemic equivalents)
      5. Stress tests and imaging
      6. Secondary prevention goals at target?

Angina Pectoris (C0002962)

Definition (MSH)The symptom of paroxysmal pain consequent to MYOCARDIAL ISCHEMIA usually of distinctive character, location and radiation. It is thought to be provoked by a transient stressful situation during which the oxygen requirements of the MYOCARDIUM exceed that supplied by the CORONARY CIRCULATION.
Definition (CSP)recurring thoracic pain or discomfort which occurs when a part of the heart does not receive enough blood; usually caused by exertion or excitement.
Definition (NCI)A heart condition marked by paroxysms of chest pain due to reduced oxygen to the heart.
Definition (NCI)Previous or current symptoms described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia.
ConceptsSign or Symptom (T184)
ICD9413, 413.9
MSHD000787
BasqueBULARRALDEKO ANGINA
DanishAngina pectoris
DutchAngina pectoris
EnglishAngina, Angina Pectoris, ANGINAL PAIN, Anginal syndrome, Angor Pectoris, AP - Angina pectoris, Cardiac angina, Ischaemic chest pain, Ischaemic heart disease - angina, Ischemic chest pain, Ischemic heart disease - angina, Stenocardia, Stenocardias
FinnishRINTAKIPU/ANGINA PECTORIS
FrenchAngine de poitrine
GermanAngina pectoris
Hebrewteukat xaze
Hungarianangina pectoris
ItalianAngina pectoris
NorwegianHJERTEKRAMPE/ANGINA PECTORIS
PortugueseAngina de peito
Spanishangina, angina cordis, angina de pecho, angina pectoris, angor, angor pectoris, cardiopatia isquemica, dolor toracico isquemico, estenocardia, sindrome anginoso
SwedishANGINA PECTORIS
Parent ConceptsCoronary Artery Disease (C1956346), Coronary atherosclerosis and other heart disease (C0810003), Coronary heart disease (C0010068), Coronary Arteriosclerosis (C0010054), Coronary Vessel Disorders (C0549517), Myocardial Ischemia (C0151744), circulatory system (C0497231), Diagnosis/Diseases Component (C0497531), Chest Pain (C0008031), Pain (C0030193), Cardiovascular System Signs and Symptoms (C1332855), Angina Pectoris (C0002962), Heart Diseases (C0018799), Ambiguous concept (C1274012), Duplicate concept (C1274013), Disorder characterized by pain (C1300028)
SourcesAOD, CCS, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Angina Pectoris, Variant (C0002963)

Definition (MSH)A clinical syndrome characterized by the development of CHEST PAIN at rest with concomitant transient ST segment elevation in the ELECTROCARDIOGRAM, but with preserved exercise capacity.
Definition (NCI)A variant form of angina pectoris caused by coronary artery vasospasm, usually occurring spontaneously and frequently associated with ST segment elevation.
Definition (NCI)(syn. Prinzmetal's angina or coronary artery vasospasm). It usually occurs spontaneously, and unlike typical angina, it nearly always occurs when a person is at rest and does not require physical exertion. It frequently is associated with transient ST-segment elevation.
ConceptsDisease or Syndrome (T047)
ICD9413.1, 413.1
MSHD000788
EnglishANGINA VARIANT <PRINZMETAL>, ANGINA VARIANT PRINZMETAL, Coronary artery spasm angina, Prinzmental angina, Prinzmetal Angina, PRINZMETAL VARIANT ANGINA, Prinzmetal's Angina, Prinzmetals Angina, Variant angina, Variant angina pectoris
Spanishangina de pecho variante, angina de Prinzmetal
Parent ConceptsAngina Pectoris (C0002962), Unstable angina (C0002965), Coronary Artery Vasospasm (C0010073), Cardiomyopathies (C0878544)
SourcesCOSTAR, CSP, DXP, ICD9CM, MSH, MTHICD9, NCI, NDFRT, QMR, RAM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Myocardial Ischemia (C0151744)

Definition (MSH)A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (CORONARY ARTERY DISEASE), to obstruction by a thrombus (CORONARY THROMBOSIS), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (MYOCARDIAL INFARCTION).
Definition (NCI)A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries, to obstruction by a thrombus, or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (myocardial infarction).
Definition (CSP)blood deficiency in the myocardium caused by a constriction or obstruction of its blood vessels; frequently occurs in conjunction with hypoxia, which is reduction in oxygen supply.
ConceptsDisease or Syndrome (T047)
ICD9410-414.99, 414.8, 414.9
MSHD017202
EnglishCardiac ischaemia, Cardiac ischemia, HEART DIS ISCHEMIC, IHD, IHD - Ischaemic heart disease, IHD - Ischemic heart disease, Ischaemic heart disease, ISCHEMIA MYOCARDIAL, ISCHEMIC HEART DIS, Ischemic heart disease, Ischemic Heart Diseases, MYOCARDIAL ISCHAEMIA, myocardial ischemia, myocardial ischemia/hypoxia, Myocardial Ischemias
Spanishcardiopatia isquemica, enfermedad cardiaca isquemica, enfermedad isquemica del corazon, isquemia miocardica
Parent Conceptsvascular ischemia (C0679395), Heart Diseases (C0018799), Ischemia (C0022116), Coronary Arteriosclerosis (C0010054), Arterial and Arteriolar Disorders (C0549520), Circulatory system disease NOS (C0728936), Vascular Diseases (C0042373), Non-Neoplastic Heart Disorder (C1335015), Myocardial Ischemia (C0151744), Cardiomyopathies (C0878544), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, CST, DXP, ICD9CM, LNC, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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