Internal Medicine

0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54

Coronary Artery Injury Coronary Syndromes, Acute 407

specific therapy

n/a

follow-up

n/a

complications and prognosis

■Similar to acute MI (see Coronary syndromes)

Coronary Syndromes, Acute............................

KENDRICK A. SHUNK, MD, PhD

history & physical

History

■Angina or suspected angina persistent for >20 minutes requires

immediate rule-out of STEMI by ECG (within 10 minutes)

■When STEMI ruled out, perform early stratification of risk of death

➣Clinical assessment of likelihood (high, intermediate, or low) of

acute ischemia caused by CAD

➣5 most important factors for likelihood: Nature of symptoms,

H/O CAD, age, sex, # of risk factors

➣Traditional risk factors: diabetes, hypertension, male, age, smok-

ing, high LDL, low HDL, family history

➣Other risk factors: h/o elevated CRP, homocysteine, Lp(a)

■High risk historical features (1 or more=high risk)

➣Accelerated tempo of ischemic symptoms in preceding 48H

➣Prolonged ongoing (>20 min) rest pain

■Intermediate risk historical features (1 or more but without high risk

features)

➣Prior MI, Peripheral or cerebrovascular disease, CABG, prior

Aspirin use

➣Prolonged but resolved (>20 min) rest angina with mod or high

likelihood of CAD

➣Rest angina (<20 min or relieved by rest or sublingual nitro)

■Not a high or intermediate risk historical feature:

➣New-onset in the past two weeks of Canadian Class III or IV

angina (angina walking 2 blocks or less)

Signs & Symptoms

(one or more makes pt high risk)