CARDIOLOGY NOTES

CHEST PAIN
Myoglobin (1-4h after onset, very nonspecific thoughyou order b/c a normal test
at 4 hours excludes current infarction)
CK-MB and Troponin levels do not rise until 4-6 hrs with peak at 12-24. CK-MB
remains elevated for 2-3 days, whereas Troponin remains elevated for 1-2 weeks).
All patients with unstable angina (acute coronary syndrome) need 2 antiplatelet
meds. ASA + Blockers of P2Y12 adenosine diphosphate (ADP) receptor on platelets
(Clopidogrel or ticagrelor (also prasugrel)). Note prasugrel is only given when
angioplasty is done. Note heparin is not as useful in acute ST elevation like it is in
unstable angina or NSTEMI.
Defined: angioplasty is a type of PCI. PCI must be performed within 90 minutes of
arrival at ED.
Mechanisms of Antiplatelet Meds

Inhibition of TXA2-dependent platelet function and inactivation of platelet

COX-1 = Aspirin
o Aspirin alone reduces mortality by 25% for AMI and 50% for UA
Blockade of ADP receptor on platelet (inhibit ADP activation of plts: block the
aggregation of plts to each other by inhibiting ADP-induced activation of
P2Y12 receptor)= clopidogrel, prasugrel, ticagrelor
o Clopidogrel and prasugrel are in the thienopyridine class.
o Only use prasugrel when doing angioplasty
Potentiation of antithrombin III= heparin
Thrombin Inhibition= argatroban, lepirudin

Mechansim of Thrombolytics
1. Thrombolytics activate plasminogen into plasmin.
2. Plasmin chops up fresh or newly formed fibrin strands into D-dimers (this is
why D-dimers elevated with all clots).
3. Factor 13 stabilizes the fibrin clot after several hoursat which time plasmin
will not cleave fibrin.
If angina with normal EKG or a ST depression (& no contraindication to anticoag):
heparin alone
Angioplasty within 90 minutes of arrival or thrombolytics within 30 minutes of
arrival.
Angioplasty is superior to thrombolytics in terms of outcomes such as mortality,
incidence
of CHF, and recurrences of chest pain. Only 20% of hospitals in the United States
can do
urgent angioplasty with intervention.

Emergency coronary bypass when thrombolytics and angioplasty have been

performed and there is still evidence of ongoing ischemia.
Thrombolytics produce a 25% reduction in mortality when used in the 1 st 6 hours.
Indications for thrombolytics are:

Chest pain starting within last 12 hours with either:

o > 1 mm ST elevation (in 2 or more leads)
o NEW LBBB
Note: tPA use within 3-4.5h of onset of stroke symptoms (not 12hs)

Absolute CI to thrombolytics (tPA, streptokinase, alteplase, APSAC, reteplase,

tenecteplase)

Severe GI bleeding (how severe? Bleeding ulcer, etcDRE?)

Intracranial hemorrhage (potential SAH?)
Recent surgery (how recent?)
Aortic dissection
Any active internal bleeding

Relative CI to thrombolytics

Bp >180/110
Active ulcers
Recent head trauma (how recent?)
Pregnancy

Do not use streptokinase in pts who have had it before!!

Mortality Benefit in Myocardial Infarction
Aspirin
Second antiplatelet drug
Angioplasty
Thrombolytics
Beta-blockers
Statins
Increase Blood Flow With

Thrombolytics (or Angioplasty)

ASA
Nitrates

Decrease HR & Myocardial Contractility (and therefore decrease myocardial work

and O2 consumption

BB (use CCB if:

Improve myocardial remodeling (and therefore decrease mortality)

ACEi

MC complication of acute MI in 1st 3 days: Arrhythmia (and is why need to place in

Critical Care Unit)
Use Poiseuilles equation: Flow is proportional to the radius raised to the fourth
power. So a
doubling in radius or diameter will increase flow by 16 times (2 2 2 2).
PCI w sirolimus-coated stent vessel diameter increased from 2mm to 4mm
=16x increase in flow
CCS Sequence
1. Start with pain mngt:
a. MONA
i. morphine IV x1
ii. oxygen
iii. nitroglycerine sublingual x1
iv. aspirin
b. tests:
i. vitals q1h
ii. pulse oximeter
iii. IVA
iv. cardiac monitor
v. BMP (also CBC, UA)
vi. CXR
vii. EKG 12 lead (the most important test)
viii. cardiac enzymes x3. (CK-MB, Troponin, Myoglobin)
2. Then get focused PE => normal=> get full PE including rectal (the pt will
probably need heparin).
a. CV, Pulm (Chest); HEENT
3. Advance the clock for EKG result, shows STEMI (if it is negative, then you
need to rule out non-STEMI with cardiac enzymes).
4. Start BBL (metaprolol; decrease mortality), clopidogrel, heparin x24 hrs,
abciximab (Reopro; continue for 1 yr if there is a stent, if not then just for
1 wk), statin, cardiology consult for cardiac catheterization (do
thrombolysis with tPA only if cannot get cardiac catheterization promptly).
5. It will give you EF (if EF is low start ACEI) and show a blood clot. Check
PT/PTT.
6. Follow CBC for possible HIT, BMP for possible contrast nephropathy, check
lipid panel, check diet.
7. Counsel for sex activitiy, exercise, education, smoking.
8. Get cardiac rehab.
9. Get submaximal stress test in 1 wk after STEMI for exercise
recommendations (not used that often now). For non-STEMI (without
cardiac catheterization) proceed with full stress test in 1 wk if there is
ongoing ischemia. If the pt cannot walk on the treadmill get
pharmacological persantine or depyridamole test.