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Cardiology

[MYOCARDIAL ISCHEMIA]

Introduction
Myocardial ischemia is produced where there is an occlusion to
blood flow. Its caused by chronically progressive
atherosclerosis limiting perfusion to the myocardium. This
produces ischemia when cardiac demand increases; theres an
imbalance in the demand to supply ratio. When an acute
thrombus forms from endothelial injury the lumen can quickly
become occluded (an MI). Over time, the patient will undergo
infarction with permanent loss of myocardial tissue.
Risk Factors
HTN
Smoking
Dyslipidemia
DM
Cocaine

Risk Factors
Since this is a result of progressive atherosclerosis those things
which perpetuate atherosclerosis will lead to ischemic heart
disease. Risk factors provide something to fix and help steer the
diagnosis. What makes this interesting is HOW you fix these risk
factors. Theyre HTN, smoking, dyslipidemia, diabetes, and
drug use (i.e. cocaine).
Patient Presentation
Myocardial ischemia on its own is painful. It causes a crushing,
retrosternal chest pain that will radiate down the arm and up
the jaw. It may also present with dyspnea. Ischemia on its own
will not cause mechanical failure. Other signs and symptoms will
be a result of myocardial infarction and necrosis. If the Left
Heart fails its pulmonary edema. If the Right Heart fails its
hypotension and peripheral edema. Any infarct can produce
arrhythmias: atrial, ventricular - whatever. Separating severity
of ischemia is typically based on whether or not the pain is
relieved with rest and/or nitrates. Beyond that, laboratories are
needed to differentiate between the bad ones (STEMI,
NSTEMI).
Diagnosis
The first test is the ECG. Its noninvasive, cheap, and able to
detect the highest acuity disease (STEMI). It also establishes an
admission baseline for comparison. A 12-Lead ECG is best. ST
segment elevation = transmural infarct = STEMI.
To rule out active myocardial infarct you need cardiac
biomarkers (Troponins, CKMB, etc). These are released from
dying or dead myocytes. They separate unstable angina from
NSTEMI.

Pain
Relief
Biomarkers
ST s
Pathology

Stable
Angina
Exercise
Rest +
Nitrates

70%

Unstable
Angina
@ rest

NSTEMI

STEMI

@ rest

@ rest

90%

90%

100%

Typical
Levine Sign
Crushing Chest Pain
Pale, Cool, Diaphoretic
Sense of Impending Doom

Diagnosis
In Acute disease (guy in the ER with active chest pain)
get EKG, Troponins, and Cath.
In Chronic disease (guy in office with an h/o chest pain)
get an EKG and Echo/Stress Test.
Chest Pain
ST s

EKG

Multiple options exist for confirming the diagnosis of myocardial


ischemia based on severity and acuity. There is the stress test (for
someone who has neither NSTEMI nor STEMI) and the best test
which is coronary catheterization. The higher the acuity, the
more likely the cath. Lets talk about the low-acuity setting first.
Able to
Exercise

STEMI
Emergently

STs
Routine tests such as CXR / CBC / TSH / CMP are obtained but
do not influence the diagnosis or management.

Atypical
Fatigue
Malaise
SOB

CATH

NSTEMI

Biomarkers
Troponin,
CKMB
Unstable Angina

Stress Test
Unable To
Exercise

Treadmill Dobutamine
or Adenosine

Normal
EKG

Abnormal
EKG

EKG test

Echo or
Thallium

Treat with
medications then
Manage
Medically

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Cardiology

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[MYOCARDIAL ISCHEMIA]

Diagnostic Modalities
The stress test
a) Treadmill stress test - Requires the patient to be able to
exercise (80% of max heart rate) and requires a normal ECG.
Send him/her on an exercise and stop the test when there are
EKG changes (ST depression or T wave inversion) or Chest
Pain. If positive, go immediately to cath.
b) Dobutamine Stress Test Uses a pharmacological challenge
and an Echo. Under the challenge (85% max HR), the echo will
pick up hypokinesis or akinesis (decreased wall motion).
Areas that are infarcted will persist with akinesis even at rest.
Areas that become ischemic under stress (become akinetic) will
move again after dobutamine is removed (revealing
salvageable tissue).
c) Nuclear Stress Test Thallium looks like sodium to the heart.
It will be picked up by myocytes and light up healthy tissue.
Infarcted tissue will not under both rest and exercise. Ischemic
tissue will not under stress, but will at rest (revealing
salvageable tissue).
Catheterization
This is the best test for the diagnosis of coronary artery disease.
It assesses the severity of stenosis AND helps rule out
Prinzmetals angina (clean coronary arteries producing
ischemia as a product of vasospasm - treat with CCB).
Therapy
Adjust risk factors
a. LDL the goal is to LDL < 100 or <70 for active disease and
get HDL > 40. Do this with statins. Other drugs exist, but
start with statins. Use Fibrates if there is a contraindication to
statins.
b. DM tight glucose control to near normal values (80-120 or
HgbA1C < 7%) with oral medications or insulin.
c. HTN regular control of blood pressure to <140 / <90 with
Beta-Blockers (reduce arrhythmias) and ACE-inhibitors.
Titrate heart rate to between 50-65bpm and 75% of the heart
rate that produced symptoms on stress test.
Reduce Risk of Thrombosis
Manage this with either Aspirin (Cox-Inhibitor) or Clopidogrel
(ADP-inhibitor) long term. Those spiffy Glycoprotein IIb/IIIa
inhibitors like Abciximab are useful in the patient going for cath
with stenting for additional antiplatelet effect, but they are not for
long term.
Surgical Management
Surgical management choices are angioplasty or CABG. The
decision is made based on the severity of occlusive disease. If its
really bad (i.e. requires multiple stents) do a CABG. If the
atherosclerosis is global and no ground can be found for the stent,
do CABG. Stents are now drug-eluding (require Clopidogrel) or
bare-metal (do not require Clopidogrel)
Thrombolytics
Either the administration of tPA (within 12 hours of onset) or
heparin is done only when catheterization is not available AND
they are in an acute disease (NSTEMI or STEMI).

Cant Exercise: Peripheral Vascular Disease,


Claudication, vasculitis, diabetic ulcers, SOB at rest, etc.
Cant Read ECG: Any BBB or old infarct

Dead Things Dont Move


Stress

Normal
Wall
Motion

Akinesis

Akinesis

No Dz

Ischemia

Infarct

Normal
Wall
Motion

Normal
Wall
Motion

Akinesis

At Rest
Acute Presentation: MONA-BASH
Morphine
Beta-Blocker
Oxygen
ACE-inhibitor
Nitrates
Statin
Aspirin
Heparin
Treatment
Statins
-Blockers
ACE-i
ASA
Clopidogrel
Angioplasty
CABG
tPA
Heparin

When to use it
Goals
Any ACS
LDL < 70
HDL > 40
Any ACS
SBP < 140
DBP < 90
Any ACS
SBP < 140
DBP < 90
Any ACS
No goal
ASA allergy or
No goal
drug-eluding
stents
ST or + Stress; 1 or 2 vessel disease
ST or + Stress; Left-Mainstem or 3 vessel disease
ST or + Stress; no PCI available, no transport
ST or + Stress; contraindication to tPA,

CATH
Angioplasty
(PCI)

Left Mainstem

1,2 Vessel
CATH

CABG

3 Vessel Disease

Surgery = Left Mainstem OR 3-vessel disease; surgery = CABG


Angioplasty = 1,2 Vessel Disease

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