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ACS (Acute Coronary Syndrome)

Spectrum of problems ranging from unstable angina to MI
Crushing pain/p­res­sure; radiation to jaw, back, and left arm; SOB, diapho­resis, N/V; impending sense of doom
Most common etiology of MI
Preexi­​sting athero­​sc­l​e­rotic plaque​ ➔ ​thr​ombus format­​ion​ ➔ ​pro​l­onged myocardial ischem​ia ➔ MI
EKG changes
Acute MI: progre­​ssion from peaked T- wave​s ➔ ST​-de­​gment elevat­​io­n​/­de​­pre­​ssi​on ➔ Q​-wa​ve ➔T​-wave inversions (hours­​-days)
Laboratory Tests
EKG (within 10 min), troponin levels, CK:CK-MB ratio, MRI with gadolinium
Stable Angina
Reprod­ucible pain, improved with rest, lasts <10min,
Occurs more often with less activity, not relieved with NTG, lasts >10min, EKG changes
Complete occlusion, EKG changes
Initial Treatment
ONAM: Oxygen, +/- nitro, antipl­atelets (ASA+P­2Y12), morphine (PRN), EKG monito­ring, IV access
Discharge Treatment
1) ASA (life)
2) P2Y12 (1yr)
3) Statin
4) ß-blocker
5) ACE-I
6) Aldost­erone antagonist
Emergency Interv­ention
Door-t­o-n­eedle within 30min; door-t­o-b­alloon within 90min

Congestive Heart Failure (CHF)

Inability of the heart to keep up the the demands on it and pump blood with normal efficiency
Result of one or more of the following
Contra­​ctile ability of heart muscle, preload and after load of the ventricle, and heart rate
MI, perica­​rdial disorders, valvular disorders, congenital abnorm­​al­i​ties, and non cardiac causes (high-­​output heart failure from thyrot­​ox­i​cosis or severe anemia)
Clinical features of HFrEF/LHF
Exertional dyspnea, non-pr­​od­u​ctive cough, fatigue, orthopnea, PND, basilar rales, gallops, exercise intole­​rance
Clinical features of HFpEF/RHF
Distended neck veins, hepatic conges­​tion, nausea, dependent pitting edema, *edema + hepato­​me­galy, (R-sided failure often caused by L-sided failure)
1) Loop
2) ACE-I
3) ß-blocker
4) Spiron­ola­ctone
5) Hydral­azine + ISDN (esp in blacks)


Primary HTN
Causes 95% of cases of HTN; multif­​ac­t​orial pathog­​enesis (genetics, salt, obesity, RAAS, NSAIDs, smoking, lack of exercise, metabolic syndrome)
Secondary HTN
Narrowing of aorta, RAS, chronic steroids, Cushings syndrome, pregnancy, thyroid and parath­​yroid disease, primary hypera­​ld­o​s­te​­ronism, parenc­​hymal renal dz)
Treatment Goal
All ages with DM or CKD ≤140/90
Ages <60yo ≤140/90
Ages ≥60yo ≤150/90
First line: ACE-I/ARB, CCB, thiazides
Other: alpha blockers, clonidine, guanfa­cine, hydral­azine, minoxidil,

Ischemic Heart Disease

Charac­​te­rized by insuff­​icient oxygen supply to cardiac muscle
1) Athe​r­os​­cle­​rotic narrowing (most common). 2) Constr­​iction of coronary arteries. 3) (Rare) congen­​ital, emboli, arteritis, dissection
Risk Factors
Metabolic syndrome, male, older age, smoking, FmHx, HTN, DM, low-es­​trogen state, abdominal obesity, inacti­​vity, dyslip­​id­emia, EtOH, low fruits­​/v­e​ggies (cocai​ne ➔ MI)
Un/stable Angina
See Above
Prinzm­etal's (Variant) Angina
Caused by vasospasm at rest, exercise capacity preserved. Treated with CCBs, avoid ß-blockers
EKG Findings
Horizontal or downsl­​oping ST-segment depression
Lifestyle changes, nitrates (nitro and LA), B-bloc­​kers, CCB, Ranola­​zine, ASA/Cl­​op­i​d­igrel, revasc­​ul­a​r­iz​­ation


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