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Cardiac enzyme/marker interpretation (troponin, CK-MB, BNP) Troponin: Troponin is a protein in heart muscle cells that regulates muscular contraction. When the heart muscle is damaged, as in a heart attack, troponin is released into the bloodstream. Troponin levels can become elevated 3-4 hours after a heart attack and can remain elevated for up to 14 days. Therefore, it is a highly specific indicator of heart damage. CK-MB (Creatine Kinase-MB): CK-MB is a form of creatine kinase found mostly in the heart muscle. Levels in the blood can rise within a few hours of a heart attack and generally peak within 24 hours. A high CK-MB level often indicates damage to the heart. However, CK-MB is less specific for heart damage than troponin, as it can also be elevated in conditions such as muscle injury, inflammation, or vigorous exercise. BNP (B-type Natriuretic Peptide): BNP is a hormone produced by the heart and blood vessels. The level of BNP in the blood increases when the heart is working hard and has more fluid than it should. High levels of BNP are often associated with heart failure. This test is often used to differentiate between heart failure and other conditions (like lung diseases) when a patient presents with shortness of breath. Additional Laboratory Tests · Troponin every 8hr · BNP to assess for heart failure · CBC provides information needed for thrombolytic therapy (H/H and platelet baseline) · PTT, PT/INR to assess baseline coagulation status · BMP to assess renal function and electrolytes · TSH, magnesium, and phosphorus as imbalances can cause dysrhythmias · echocardiogram to evaluate the ejection fraction and patency of heart valves · coronary angiography Differentials for angina Unstable angina: acute cardiac chest pain that comes and goes without relation to exertion along with ST segment depression or T-wave inversions. Cardiac enzymes are normal NSTEMI: elevated cardiac enzymes with acute cardiac chest pain or/and ECG changes (ST segment depression or T-wave inversion) STEMI: acute cardiac chest pain, ST segment elevations, and elevated cardiac enzymes Stable Angina: is a pattern of exacerbation with physical or emotional stress caused by a supply–demand mismatch. It lasts several minutes and is relieved by rest. Variant/Prinzmetal: Occurs in the presence of arterial spasm and is unrelated to CAD. More common in women. Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More Risk factors for cardiac ischemia · Age 55 years · Family History of CAD · Tobacco use · Diabetes · HTN · Hyperlipidemia · Vascular atherosclerosis · Obesity · Unhealthy diet · Inactivity · COVID-19 Appropriate diagnostic testing in PFO(Patent Foramen Ovale) An echocardiogram can be done to diagnose a PFO. If the PFO is not easily seen, a cardiologist can perform a "bubble test." Saline solution (salt water) is injected into the body as the cardiologist watches the heart on an ultrasound (echocardiogram) monitor. EKG interpretation in ACS/MI Inferior wall: II, III, & aVF--RCA & LCx Intraventricular septum: V1-V2--LAD Anterior wall: V3-V4--LAD, LCA Lateral wall of the left atrium and septum: I, aVL, V5, & V6--LCx Right atrium: aVR--RCA Management of chest pain in CAD The 7 early treatment measures in ACS: 1. Oxygen 2. Nitroglycerine 3. Morphine 4. Beta-blocker 5. Aspirin 6. Clopidogrel 7. Anticoagulation Admission vs discharge considerations in CAD/ACS Patients with NSTEMI, unstable angina, or STEMI will be discharged with DAPT for at least 1 year. Continuation of DAPT versus aspirin-only beyond that is based on the type of stent placed (if applicable) and cardiologist preference. High-intensity statins will also be continued in ACS patients. Additionally, ACS patients should also be discharged on a beta-blocker and a high-intensity statin. Blood pressure should be optimized to a goal of 120/80 following JNC-VIII or AHA recommendations. Outpatient medication management S/P STEMI Treatment · chewable ASA 325mg · high dose atorvastatin or rosuvastatin · Beta-blocker (avoid in cocaine-induced STEMI) · Morphine (only for severe pain; use with caution) · oxygen for SaO2 90% · sublingual NTG x 3 tablets followed by NTG drip if pain not resolved (contraindicated with RV infarct). Return to light exercise should follow the cardiologist's recommendations and will depend on the extent of the injury. Cardiac rehabilitation, which involves intense CAD education and lifestyle management interventions, including weight management, should be considered for all ACS patients. Patients who use tobacco or illicit drugs should be advised to quit. Smoking cessation education and treatment options provided to the patient should also be well-documented Differentials for atrial fibrillation cardiomyopathy congestive heart failure, heart disease hyperthyroidism, acute alcohol intoxication myocardial infarction pulmonary embolism pericarditis cardiac surgery obesity, hypertension, diabetes mellitus sleep disordered (OSA) Identification of arrhythmias (tachycardia, afib, BBB, SVT, Vtach) Tachycardia • Rate over 100 • Treat if symptomatic • Underlying cause (wide range of these) • Cigarette smoking • Hypovolemia • PAIN • Illicit drugs • Stimulants • Beta blockers • When HR increases there is less time for atrial filling, less atrial kick. PAT and SVT • Paroxysmal atrial tachycardia • PAT also called Atrioventricular Nodal Reentry Tachycardia (AVNRT) • Supraventricular tachycardia • Vagal maneuvers • Adenosine – 6mg then 12mg fast • Ca channel blkrs or beta blkrs • Cardioversion if hemodynamically unstable and refractory to meds • Everything that originates above the bundle branches • Narrow QRS. Adenosine Administration • Slows cardiac conduction through the AV node and interrupts reentry pathways • Given by RAPID IV bolus • 6 mg over 1-3 seconds followed by a 20 mL NS bolus; followed by 12 mg dose. Atrial fib with RVR In some cases of AFib, the fibrillation of the atria causes the ventricles, or lower chambers of the heart, to beat too fast. This is called a rapid ventricular rate or response (RVR). • Rapid or fluttering heartbeat. • Chest pain, shortness of breath, dizziness, or passing out. • It can cause serious complications and requires treatment. • Lose atrial kick. Fib/Flutter Treatment • Rate control • Anticoagulation • Rhythm conversion o Meds o Cardioversion o Ablation Antiarrhythmics • Cardizem (diltiazem) • Lanoxin (digoxin). Cordarone (amiodarone) • Betapace (sotalol) • Lopressor (metoprolol). BBB Conduction block in the left or right bundle branch. • Bundle branch block is diagnosed by looking at the width and configuration of the QRS complexes. Differentials for chest pain Cardiac: Aortic Dissection, Myocarditis, Pericarditis, Takotsubo Cardiomyopathy. Musculoskeletal: Costochondritis, Rib Fractures, Muscle strain Pulmonary: PA, Pleuritis, PE Psychiatric: Anxiety and Delusions GI: Cholecystitis, Colic, esophagitis, reflux, or GERD, and ulcer Findings in ACS secondary to CAD · Aortic aneurysm-may present with chest pain, shortness of breath, as well as sudden intense, ongoing persistent mid-back pain. If the aneurysm ruptures, there is often a loss of consciousness, hypotension, and trouble breathing. · Congestive heart failure-may complain of shortness of breath, chest pain, fatigue, loss of appetite, inability to exercise or mobilize for short distances. · Atrial fibrillation patients may describe shortness of breath or an irregular heartbeat, or a feeling like "horses running" in the chest. · Drug use primarily with amphetamine use, which can cause tachycardia and myocardial infarction. · COVID-cytokine storms can occur, leading to disruption of clotting mechanisms, which can result in bleeding, clot formation, and MI. · Gastroesophageal reflux disease/indigestion-reflux can produce burning in the chest, which can be confused with chest pain. · Panic attacks-often produces tachycardia, hyperventilation, dizziness, a sense of doom, and heaviness in the chest. Differentials and risk factors for VTE Differentials are not limited to: cellulitis injury baker's cyst superficial thrombophlebitis. Risk Factors: Hypercoagulability Hereditary & non-hereditary coagulopathies Autoimmune disorders (SLE, RA, hyperthyroidism,