6 cardinal symptoms of CVS: fatigue, palpitation, chest pain, SOB, leg swelling/edema,

syncope
Following groups are said to have to UA
1. New onset (˂2months) that is severe (NYHA Class III) and/or frequent (˃3
episodes/day)
2. Accelerated angina (previuosly chronic stable angina which becomes distinctly more
frequent, severe, prolonged or precipitated by less exertion than b4)
3. Angina at rest ˃ 20 minutes

UA/NSTEMI
Symptoms Chest pain: retrosternal/central/in left chest may radiate to jaw or UL
: crushing, pressing, burning in nature
: variable severity
Atypical presentations in women, diabetic, elderly
 Dyspnoea without any history of chest pains.
 Unexplained fatigue, sweating, syncope and presyncope, epigastric
discomfort, N/V

Why diabetic don’t have typical symptpms: autonomic neuropathy masks

the symptoms
PE 7 things in CVS need to examine
 Tender hepatomegaly
 splenomegaly
 Hepatojugular reflex
 Ascites
 Pulsatile liver (RHF)
 Pulsatile epigastrim (AAA)
 Renal bruit: renal artery stenosis

Look for signs of

i. LVF (hypotension, respiratory crackles or S3 gallop)
ii. Uncontrolled HPT
iii. Anaemia
iv. Thyrotoxicosis
v. Severe aortic stenosis
vi. Hypertrophic cardiomyopathy
vii. Lung disease

IX i. ECG during acute episodes (within 10 minutes of arrival at casualty)

& serial ECG. Features usggesting UA/NSTEMI
 ST depression ˃0.05mV in 2 or more contiguous leads
 T –wave inversion ˃0.2Mv (symmetrical T-wave inversion esp in
pre-cordial leads)

1
 ii. Cardiac biomarkers: Tn I, Tn T, CK-MB
 Tn I, Tn T are recommended
 Negative in ˂6 h from admission
 Should repeat 6-12 h after admission

iii. Echo
iv. CXR
v. Blood test: FBC, PT, APTT, LFT, RP, lipid profile, RBS
How to history + dynamic ECG changes (without persistent ST elevation), + raised
diagnosed cardiac biomarkers ( not elevate in UA, while elevate in NSTEMI)
Risk  based on history, examination, ECG, cardiac biomarkers, echo
stratification  Criteria for high & low risk for death or MI
 Determine mx & prognosis

High risk Low risk

HISTORY
 ˃70 years  Chest pains in the absence of
 Male any of the greater likelihood
 DM characteristics
 Chest or left arm pain or  Recent cocaine use
discomfort as chief symptom
reproducing prior documented
angina
 New chest or left arm pain or
discomfort as chief symptom
 Known history of CAD,
including MI
EXAMINATION
 Transient MR murmur, Chest discomfort reproduced by
hypotension, diaphoresis, palpation
pulmonary edema, or rales
 Extracardiac vascular disease

2
 ECG
 Transient STsegment deviation  T-wave flattening or inversion
(1 mm or greater) less than 1 mm in leads with
 Twave inversion in multiple dominant R waves
pre-cordial leads  Normal ECG

CARDIAC BIOMARKERS
↑ cardiac TnI, TnT, or CK-MB normal
markers
ECHO
LV dysfunction & LV ejection Normal LV function
fraction of ˂40%
TIMI risk TIMI: Thrombolysis in MI
factor TOTAL: 7
 Low risk: ≤ 2 points
 Moderate risk: 3-4 points
 High risk: ≥ 5 points
MX UA/NSTEMI
i. Admit CCU
ii. O2 by nasal prong, face mask if Spo2 ˂ 95%. (Spo2 ˃ 90% to reduce
infarct size in MI)
iii. Continuous ECG monitoring
iv. S/L GTN (avoid if SBP <90mmHg)
v. IV morphine 2.5mg + 10mg metoclopramide (morphine cause
vomiting)
vi. BB if no C/I (BA, heart block)
vii. CCB : if C/I to BB
: continuous angina despite use GTN, BB
: variant angina
viii. ACEI/ARB: LV dysfunction or DM
ix. Statin
x. Anti-platelet: aspirin = 300mg chewing
Clopidogrel = 300-600 mg oral
xi. Anti-coag: SC LMWHs or IV UFH
Post-hosp 1. Acute phase of UA/NSTEMI is within 1 to 3 months: high risk of
discharge recurrence
2. Important discharge instructions:
 Medications given: aspirin, BB, statin, ACEI (LV dysfunction, DM,
HPT, CKD), ARB (ACEI intolerance), aldosterone receptor antagonist:
spironolactone, epleronone (heart failure that already treated with
ACE-I and BB)
 education on those medication
 patients given sublingual nitrates should be instructed in its proper
and safe use
 lifestyle change and CV risk factors modification

3
 Risk fx modification
Smoking cessation
Weight Within normal BMI
Exercise minimum of 30–60 minutes of moderate activity
everyday (walking, cycling, swimming or other
equivalent aerobic activities)
Diet low cholesterol or low saturated fat diet.
Lipid Aim LDL-C < 2.0 mmol/l
Hypertension Aim for <140/85 mmHg. In diabetics: <130/80
mmHg. In elderly patients: higher BP target may be
acceptable
DM Optimal sugar control

 scheduling of timely follow-up appointment & dates for further

investigations
i. Echo to assess LV function
ii. Treadmill stress test
iii. Stress echocardiogram – treadmill or pharmacological stress
iv. Nuclear perfusion study
v. MRI – stress MRI for ischaemia & perfusion MRI for viability
 referral to a cardiac rehabilitation program where appropriate

4
5
6
 STEMI
Reinfarction: MI that occurs within 28 days of incident event, check through
CK-MB
Recurrent: MI occurs after 28 days of incident event
HX Chest pain : begins abruptly & lasts ˃30 minutes
: centre of chest & may radiate to jaw or down left arm
: pressure, squeezing or a severe crushing pain with a sense of
impending doom. Pain may be of a burning quality & localised to
epigastrium or interscapular region resulting in a misdiagnosis
: a/w sweating, nausea, vomiting & SOB
: occur at rest or with activity

Atypical presentations in women, diabetic, elderly

 Dyspnoea without any history of chest pains.
 Unexplained fatigue, sweating, syncope and presyncope, epigastric
discomfort, N/V

Other important points to note in the history are the presence of:
 Previous history of IHD, PCI, CABG
 Risk fx for atherosclerosis
 Symptoms suggestive of previous TIA or other forms of vascular
disease

PE Similar with UA/NSTEMI

Clinical dx i.
IX ECG: ST elevation in two contiguous leads
: initial ECG may normal, equivocal or show hyperacute T-wave. Repeate
ECG at close intervals of at least 15 minutes to look for progressive ST
Changes

Location Leads ECG findings

Anteroseptal V1-V3 ST elevation, Q wave
Extensive anterior V1-V6 ST elevation, Q wave
Posterior V1-V2 ST depression, tall R wave
Anterolateral I, AVL, V5, V6 ST elevation, Q wave
Inferior II, III, AVF ST elevation, Q wave

Anterior: LAD, left circumflex artery

Inferior: right coronary artery
Serum cardiac biomarkers

ECG shows STEMI: can use CK-MB

ECG suspicious: use cTn T, cTnI

All of them are elevated in STEMI

CK-MB: useful for diagnosis of reinfarction (patient with recurrent chest pain
following STEMI, a ≥ 20% ↑ in value from last sample suggests reinfarction)
7
 ECHO detect
 New regional wall motion abnormalities in difficult diagnostic situations
 Mechanical complications of acute MI (free wall rupture, acute VSD,
mitral regurgitation)

How to Elevate cardiac biomarkers + at least one from below

diagnosed ii. Clinical history consistent with chest pain of ischaemic origin
iii. ECG changes of ST segment elevation or presumed new LBBB
iv. Imaging evidence of new loss of viable myocardium or new regional
wall motion abnormality
v. Identification of an intracoronary (IC) thrombus by angiography or
autopsy
MX STEMI
xii. Admit CCU
xiii. O2 by nasal prong, face mask if Spo2 ˂ 95%. (Spo2 ˃ 90% to reduce
infarct size in MI)
xiv. Continuous ECG monitoring
xv. S/L GTN (avoid if SBP <90mmHg)
xvi. IV morphine 2.5mg + 10mg metoclopramide (morphine cause
vomiting)
xvii. BB if no C/I (BA, heart block)
xviii. CCB : if C/I to BB
: continuous angina despite use GTN, BB
: variant angina
xix. ACEI/ARB: LV dysfunction or DM
xx. Statin
xxi. Anti-platelet: aspirin = 300mg chewing
Clopidogrel = 300-600 mg oral
xxii. Anti-coag: SC LMWHs or IV UFH
xxiii. Thrombolytic = IV infusion of streptokinase (door to needle time:
˂20min)
↓
Do risk stratification
↓
If high risk for PCI (door to ballon time ˂90min)/CABG
↓
 Give IV glycoprotein IIb/IIIa inhibitor for PCI (stentin or angioplasty)
preparation (abciximab, tirofiban, eptifibatide)
 Fondaparinux C/I in pt undergo PCI
 CABG done in triple vessels block