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 angina stays severe despite medical therapy, to plan revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)
  • 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 with continuous cardiac monitoring and IV access; give oxygen only if SpO2 <90%
• Aspirin 162–325 mg chewed, then 81 mg daily, plus a P2Y₁₂ inhibitor (ticagrelor or clopidogrel; prasugrel only once the anatomy is known and PCI is planned). Continue dual antiplatelet therapy for 12 months.
• Parenteral anticoagulation (unfractionated heparin, enoxaparin, or fondaparinux) until PCI or for the hospital stay
• Nitroglycerin (sublingual, then IV) for ongoing pain; avoid with hypotension, RV infarct, or recent PDE5-inhibitor use. Morphine only for pain that persists despite nitrates.
• Oral β-blocker within 24 hours if there is no heart failure, shock, or bradycardia
• High-intensity statin for every patient, regardless of baseline LDL; add an ACE inhibitor if EF ≤40%, hypertension, diabetes, or CKD
• Invasive strategy: coronary angiography within 24 hours for high-risk patients, and immediately for refractory angina or hemodynamic or electrical instability. An ischemia-guided approach (stress testing first) is reserved for low-risk patients.
• Replace electrolytes (K, Mg); reduce risk factors: stop smoking, lose weight, treat diabetes and hypertension (2025 ACC/AHA ACS guideline)

• 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)
• Avoid nonselective beta-blockers (eg, propranolol), which can worsen coronary vasospasm; use aspirin only at a low dose, and add aspirin plus a statin if obstructive coronary artery disease is also present
• Once diagnosis made—CCB and long-acting nitrates used for long-term prophylaxis (amlodipine)