As a Cardiology fellow, we get a lot of consults for Stable Angina.
Part 2: Some Imaging Modalities/Medications.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
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#MedTwitter #MedEd #Cardiotwitter #IMG
Part 2: Some Imaging Modalities/Medications.
*Not to use as medical advice, just tips, and always discuss with your fellow/attending*
-thread ๐งต-
#MedTwitter #MedEd #Cardiotwitter #IMG
Resting ECHO
- Look for new regional wall motion abnormalities; may be suggestive of underlying CAD
- Any impairment in LV EF, LVH and/or presence of mitral regurgitation are associated w/ higher clinical risk and poor outcome
- Used to quantify aortic stenosis / hypertrophic CM
- Look for new regional wall motion abnormalities; may be suggestive of underlying CAD
- Any impairment in LV EF, LVH and/or presence of mitral regurgitation are associated w/ higher clinical risk and poor outcome
- Used to quantify aortic stenosis / hypertrophic CM
MRI
- Used to evaluate myocardium in jeopardy
- Can evaluate RWMA and EF as well as septal myocardial perfusion
- Delayed-phase gadolinium imaging provides location/murality of myocardial scar
- Weaknesses: $$, lack of portability, issues with PPM/defibrillators
- Used to evaluate myocardium in jeopardy
- Can evaluate RWMA and EF as well as septal myocardial perfusion
- Delayed-phase gadolinium imaging provides location/murality of myocardial scar
- Weaknesses: $$, lack of portability, issues with PPM/defibrillators
Coronary CTA
- High negative predictive value > 90% w/ optimal study and patient population
- Severe coronary calcifications / previous PCI may affect imaging quality
- Can have challenges for accurate quantification for in-stent restenosis in locations distal to left main
- High negative predictive value > 90% w/ optimal study and patient population
- Severe coronary calcifications / previous PCI may affect imaging quality
- Can have challenges for accurate quantification for in-stent restenosis in locations distal to left main
Coronary Angiography:
- Class I: Severe anginal symptoms, non-invasive testing w/ high-risk features, survivors of SCD, potentially fatal tachyarrhythmia, and symptoms of CHF w/ angina.
- Can use IVUS to help quantify plaque area, artery size, & luminal stenosis
- Class I: Severe anginal symptoms, non-invasive testing w/ high-risk features, survivors of SCD, potentially fatal tachyarrhythmia, and symptoms of CHF w/ angina.
- Can use IVUS to help quantify plaque area, artery size, & luminal stenosis
Lipid Lowering Agents:
- Should use as secondary prevention with lipid-lowering therapy
- Statins: HMG CoA reductase inhibitors are most effective for lowering LDL
- Goal should be LDL < 70 mg/dL, but less CV events when LDL~30. Use PCSK9/Zetia as well if tolerated.
- Should use as secondary prevention with lipid-lowering therapy
- Statins: HMG CoA reductase inhibitors are most effective for lowering LDL
- Goal should be LDL < 70 mg/dL, but less CV events when LDL~30. Use PCSK9/Zetia as well if tolerated.
Nitrates:
- Decreases cardiac workload by reducing preload & afterload of LV
Effect:
- Redistributes blood flow to the ischemic subendocardium by decreasing LVEDP
- Vasodilation of epicardial vessels
- Improvement of collateral blood flow to ischemic tissue
- Decreases cardiac workload by reducing preload & afterload of LV
Effect:
- Redistributes blood flow to the ischemic subendocardium by decreasing LVEDP
- Vasodilation of epicardial vessels
- Improvement of collateral blood flow to ischemic tissue
Nitrates:
- Include Nitroglycerin, Isosorbide Dinitrate, and Isosorbide Mononitrate
- No survival benefit w/ nitrates for chronic stable angina
- Can have headaches (most common)
- Contraindicated w/ use of PDE-5 inhibitors b/c can lead to severe hypotension
- Include Nitroglycerin, Isosorbide Dinitrate, and Isosorbide Mononitrate
- No survival benefit w/ nitrates for chronic stable angina
- Can have headaches (most common)
- Contraindicated w/ use of PDE-5 inhibitors b/c can lead to severe hypotension
Beta-Blockers:
- Blocks B1 adrenergic receptors and decreases pressure product and myocardial oxygen demand
- Decreases tension in LV wall to allow favorable redistribution of blood flow from epicardium to endocardium
- Class I indication for stable angina; decreases mortality
- Blocks B1 adrenergic receptors and decreases pressure product and myocardial oxygen demand
- Decreases tension in LV wall to allow favorable redistribution of blood flow from epicardium to endocardium
- Class I indication for stable angina; decreases mortality
Calcium Channel Blockers:
- Blocks Ca entry into vascular smooth muscles and cardiac cells by inhibiting calcium channels
- T-type: Located in atria/SA node and affect phase I depolarization
- L-type: Contributes to entrance of Ca into cell during phase III of action potential
- Blocks Ca entry into vascular smooth muscles and cardiac cells by inhibiting calcium channels
- T-type: Located in atria/SA node and affect phase I depolarization
- L-type: Contributes to entrance of Ca into cell during phase III of action potential
Calcium Channel Blockers:
- Dihydropyridine: Bind to extra-cellular L-channel and no negative chronotropic response (Amlodipine, Nifedipine)
- Non-Dihydropyridine: Verapamil and Diltiazem; leads to the inhibition of intra-cellular calcium release
- 2nd line after BB
- Dihydropyridine: Bind to extra-cellular L-channel and no negative chronotropic response (Amlodipine, Nifedipine)
- Non-Dihydropyridine: Verapamil and Diltiazem; leads to the inhibition of intra-cellular calcium release
- 2nd line after BB
ACE-I:
- Decreases preload and to some extent afterload
- Class I: HTN, DM, CKD, or HFrEF < 40%
- Can have cough, hyperkalemia, decreased GFR
- Contraindicated w/ angioedema or b/l renal artery stenosis
- Decreases preload and to some extent afterload
- Class I: HTN, DM, CKD, or HFrEF < 40%
- Can have cough, hyperkalemia, decreased GFR
- Contraindicated w/ angioedema or b/l renal artery stenosis
Ranolazine:
- Inhibits the late sodium channel in myocytes (remains open in pathological states such as ischemia or heart failure)
- QT Prolongation is worrisome side-effect; has interactions with other CYP3A inhibitors (azole anti-fungals, macrolides, protease inhibitors)
- Inhibits the late sodium channel in myocytes (remains open in pathological states such as ischemia or heart failure)
- QT Prolongation is worrisome side-effect; has interactions with other CYP3A inhibitors (azole anti-fungals, macrolides, protease inhibitors)
One of the keys in stable angina is to risk stratify patients with stress testing with imaging (nuclear, stress ECHO, coronary CTA).
Use angiography for severe symptoms or high-risk features on stress test.
Use angiography for severe symptoms or high-risk features on stress test.
Also emphasize patient education
- Medication compliance (HTN control)
- Smoking cessation
- Diet (Mediterranean among most effective)
- Exercise (70-85% maximum HR for 30-60 minutes 5x per week)
I hope this helps! Let me know what you think! ๐
- Medication compliance (HTN control)
- Smoking cessation
- Diet (Mediterranean among most effective)
- Exercise (70-85% maximum HR for 30-60 minutes 5x per week)
I hope this helps! Let me know what you think! ๐
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