Snapshot A 67-year-old door-to-door meat salesman is brought to the emergency department by ambulance after complaining to his coworkers of sudden onset chest tightness and shortness of breath. He has pain in his chest that radiates to his left arm and jaw. He has a past medical history of type II diabetes mellitus. He has a 45 pack-year smoking history, takes aspirin and simvastatin, and has a BMI of 37. Introduction Primary cause of ischemic heart disease is atherosclerotic occlusion of the coronary arteries major risk factors include diabetes mellitus (most important and considered a CAD equivalent) smoking (#1 preventable factor) HTN high cholesterol / Hyperlipidemia (total cholesterol - HDL ratio > 5.0) family history age > 45 men, > 55 women minor risk factors include obesity lack of estrogens homocystinuria cocaine use amphetamine use Presentation Symptoms range from asymptomatic particularly in older women and diabetics to substernal tightness and/or pain and shortness of breath often diagnosed and characterized as stable angina predictable; presents with consistent amount of exertion patient can achieve relief with rest or nitroglycerin indicative of a stable, flow-limiting plaque unstable angina unpredictable; often presents at period of inactivity defined as any new angina or rapidly worsening stable angina limited improvement with nitroglycerin, and usually recurs soon afterward indicative of a ruptured plaque with subsequent clot-formation in vessel lumen Physical exam in asymptomatic patients is usually normal can demonstrate mitral regurgitation murmur and/or S4 during episodes may also include signs of CHF from prior MI including elevated JVD lower extremity edema crackles and other signs of vascular disease including bruits ischemic ulcers and diminished pulses Evaluation Cardiac catheterization for definitive diagnosis locate and assess severity of the lesion(s) CXR to rule out aortic dissection Elevated cardiac biomarkers troponin, CK, and/or CK-MB may be present EKG shows ST elevation or depression depending on severity of ischemia and Q waves Stress-testing to evaluate simultaneously with EKG, echo, and radionuclide perfusion studies for patients without a history of prior coronary artery disease, all antianginal medications (beta-blockers, nitrates, calcium channel blockers) should be held for 48 hours before a stress test for pharmacological stress tests using adenosine or regadenoson, use of dipyridamole should be held for 48 hours and intake of caffeine held for 12 hours to minimize false negative findings of ischemia Differential Myocardial infarction, aortic dissection, GERD, pericarditis, pulmonary embolism, spontaneous pneumothorax, esophageal spasm, and musculoskeletal disorders Treatment In acute coronary syndrome use morphine oxygen nitroglycerin aspirin ACEI's may also use β-blockers, GPIIb/IIIa antagonists, angioplasty Drugs that improve post-MI mortality rates include Aspirin β-blockers ACEIs ARBs and HMG-CoA reductase inhibitors NOT calcium channel blockers Prognosis, Prevention, and Complications Must control diabetes considered a CAD equivalent causing MI to often present atypically in these patients Manage hypertension (<140/90 mmHg) Manage cholesterol levels (<70 mg/dL) Encourage smoking cessation and alcohol obstention MI prevention with Aspirin or clopidogrel (for ASA sensitivities) Angina prevention with β-blockers to lower HR increase myocardial perfusion time and decrease cardiac work load nitrates + calcium channel blockers in severe or recurring cases