General Surgery Rotation

• Predictable, relieved by rest and/or nitroglycerine
• Chest pain or substernal pressure
• Lasts < 10-15 min
• Relieved with rest or NTG
• Signs: Levine sign—clenched fist over the sternum and clenched teeth when describing chest pain

Workup:

• EKG: normal, Q-waves (prior MI)
• Cardiac stress test demonstrates reversible wall motion abnormalities/ ST depression >1 mm
• Coronary angiography provides a definitive diagnosis
  • If severely symptomatic despite medical therapy and being considered for PCI
  • Patients with troublesome symptoms difficult to diagnose
  • Angina symptoms in a patient who has survived a cardiac death event and patients with ischemia on noninvasive testings

Treatment:

• • Nitroglycerin sublingual → IV NTG
  • Beta-blockers
  • Severe: angioplasty and bypass

Prognosis:

• Depends on LVEF: < 50% (increased mortality)
• Vessel(s) Involved: left main (poor, 2/3 of the heart)

• Previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
  • Chronic angina—increasing in frequency, duration, or intensity of pain
  • New-onset angina—severe and worsening
  • Angina at rest
• O2 demand unchanged, supply decreased, secondary to low resting coronary flow

Workup:

• EKG: ST-segment or T-wave abnormalities
• Cardiac enzymes: normal troponin, CK-MB

Treatment

• Admit to the unit with continuous cardiac monitoring, establish IV access, O2
• Pain control with NTG and morphine
• ASA and/or clopidogrel - (Plavix reduces the incidence of MI in patients with unstable angina compared with ASA alone 9-12 months of therapy)
• LMWH continued for at least 2 days
• β-Blockers
• LMWH
• Replace electrolytes
• If the patient responds to medical therapy → stress test to determine if catheterization/revascularization necessary
• Revascularization if symptoms persist despite medical therapy
• Reduce risk factors: stop smoking, weight loss, treat DM/HTN
• ACE inhibitors and statins - start patients with unstable angina or NSTEMI with high LDL on HMG-CoA reductase inhibitor (statin)

• Smooth muscle constriction (spasm) of the coronary artery without obstruction → leads to MI, ventricular arrhythmias, sudden death
• Known triggers: hyperventilation, cocaine or tobacco use, provocative agents (acetylcholine, ergonovine, histamine, serotonin)
• Nitric oxide deficiency → increased activity of potent vasoconstrictors and stimulators of smooth muscle proliferation 50-y-old, females

Nonexertional chest pain similar to unstable angina

• Preservation of exercise capacity
• Look for a history of smoking (#1 risk factor) or cocaine abuse
• Pain is cyclical (mostly occur in morning hours, no correlation to cardiac workload)

Diagnostics:

• EKG may show inverted U waves, ST-segment or T-wave abnormalities
• Cardiac enzymes: normal troponin, CK-MB
• Check Mg level, CBC, CMP, lipid panel

Treatment:

• Stress testing with myocardial perfusion imaging or coronary angiography
• Pharmacotherapy SL, topical, or IV nitrates (initial)
• Antiplatelet, thrombolytics, statins, BB
• Once diagnosis made—CCB and long-acting nitrates used for long-term prophylaxis (amlodipine)