Dr. Kim presented a case of a middle aged man who presented with acute dyspnea x2 weeks in the setting of chronic dyspnea of 2 years. He had a PMH of HTN, HLD, Insulin-dependent DM, hypothyroidism, and psoriasis.
Outpatient workup included resting EKG which showed pathologic Q waves in III and AVF, indicating and old inferior MI. A dobutamine stress test was performed:
Resting:
Stressed:
...which elicited chest pain and significant EKG changes: >2mm ST elevations in II, III, AVF, and >1mm depressions in I, AVL, and V2.
He was diagnosed with unstable angina and was taken to the cath lab, where angiography revealed diffuse atherosclerosis and a 99% proximal RCA culprit lesion which was stented.
ACS - comprised of:
STEMI: +EKG, +Trop
NSTEMI: -EKG, +Trop
Unstable Angina: -EKG, -Trop
- New / Change / At rest
LRs of ACS in a patient with chest pain:
Risk factors (modif/non-modif.)
Non-modifiable
PAD: 2.7
Prior CAD: 2.0
DM: 1.4
CVA 1.4
Male: 1.3
HLD: 1.3
HTN: 1.2
Modifiable
Smoker: 1.1
Sxs
Radiation to BUE: 2.6
Similar to prior ischemia: 2.2
Change in pattern in 24h: 2.0
Chest pressure: 1.9
Exertional: 1.5-1.8
Radiation to neck/jaw: 1.5
PE findings
Hypotension: 3.9
Reproducible CP: 0.28
Diagnostics
ABNL stress test: 3.1
Guideline directed Medical Management for ACS
ASA 81mg daily
P2Y12-I for 1 year (minimum 1mo for BMS, 3-6mo for DES)
Beta-blocker: Everyone
ACE-I/ARB: for anterior infarct, or post-MI EF <40%
BP goal: Goal SBP <130, DBP <80
LDL: Goal <70
Start with: high intensity statin (atorvastatin 40-80mg, rosuvastatin 20-40mg)
If on max statin but LDL >70, can add ezetimibe
If failed ezetimibe, can use PCSK9-I
Cardiac Rehab*
Mortality benefit (59% all cause, driven by cardiac (57%))
variable compliance, all comers = 33%
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