Physician Assistant Exam: Diagnose Acute Coronary Syndrome

As the Physician Assistant Exam will expect you to know, chest pain (angina pectoris) and congestive heart failure are two of the biggest reasons people are admitted to the hospital. Acute coronary syndrome encompasses many of the reasons that someone comes to the hospital: stable angina, unstable angina, and the infamous myocardial infarction (heart attack).

Some risk factors for CAD are modifiable; some are not. The modifiable risk factors for CAD include hypertension, diabetes, smoking, hyperlipidemia, a sedentary lifestyle, obesity, overuse of alcohol, and a chronic inflammatory state. Inflammation is a big risk for CAD. Non-modifiable risk factors for CAD include age, gender, and family history.

With stable angina, the patient never had any chest pressure at rest; chest pressure occurred only with activity. Chronic stable angina often occurs predictably, usually after physical activity or as a result of a significant emotional stressor.

One of the classic scenarios of stable angina is the obese middle-aged man who hasn’t engaged in any sort of physical activity. He watches the news and finds out he will get a few inches of snow. The next day, he goes out and tries to shovel the snow and ends up getting chest pressure. His wife calls 911, and he’s admitted to the hospital with acute coronary syndrome.

Other similar examples include the weekend warriors — out-of-shape older “athletes,” more commonly men, who do strenuous physical activity once a week.

By contrast, unstable angina occurs in the gentleman sitting at home watching the news and getting chest pressure while thinking about shoveling snow. Unstable angina occurs at rest.

Here are two key points concerning chest pain:

  • Men tend to have the classic pain patterns, with chest pressure and radiation to the left arm. It’s often described as more of a pressure than a sharp pain. In addition, nausea and/or diaphoresis can be present. Sometimes, especially in the setting of an acute myocardial infarction, there can be a “sense of doom” as well.

  • The patient may have symptoms typified as angina equivalents, which refers to symptoms that you can miss because they mimic the symptoms of something else. For example, some people may express cardiac chest pain through right upper-quadrant pain, midepigastric pain, or even a toothache.

Women differ from men, especially in the way they experience chest pain. Women may not experience the classic chest pressure with radiation to the left arm. They may “not feel well,” or they may have more nausea or abdominal symptoms. These symptoms cannot be discounted, and the clinician needs to look for more angina equivalents.

You’re evaluating a 67-year-old man who was admitted for a non-ST-elevation myocardial infarction (NSTEMI). He underwent a cardiac catheterization and was told that aggressive medical management was needed. Despite beta blockers, nitropaste, and aspirin, he’s still having bouts of angina. Which of the following medications could you add to his regimen at this time?

(A) Atorvastatin (Lipitor)
(B) Furosemide (Lasix)
(C) Lisinopril (Zestril)
(D) Ranolazine (Ranexa)
(E) Indomethacin (Indocin)

The correct answer is Choice (D), ranolazine. Many cardiologists prescribe this medication to provide additional help with angina symptoms for someone on maximal medical therapy. Choice (A), atorvastatin, decreases the cholesterol level and has an anti-inflammatory effect but doesn’t treat symptomatic angina.

Choice (B), furosemide, is used to treat congestive heart failure (CHF). Choice (C), lisinopril, is used for both acute coronary syndrome and congestive heart failure but again doesn’t help with symptomatic angina. Choice (E), indomethacin, is used for musculoskeletal pain and is first-line for treating pericarditis.

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