![]() ![]() S: Yeah, part of that is because coronary artery disease is a complicated spectrum. J: Often, histories are confusing and lab tests don’t always help clear things up. S: Unfortunately these classic cases happen every day, but most of the time chest pain is not really actually that clear. J: And this movie trivia goes, that’s a much sadder story, because the actor that played Leo, John Spencer, actually later died of a heart attack himself. Towards the end of the series, Leo suffered a heart attack in an eerily familiar scene with almost the classic caricature of the old man in the cold clutching his chest. S: My favorite TV show growing up was the West Wing. S: Crazy enough, McKay himself had a heart attack himself and recognized it because he had similar symptoms. Case in point – I read that in the movie Vice, the actor Christian Bale actually suggested to his writer director Adam McKay that nausea and epigastric pain can be symptoms of a heart attack, so they went with that on film. Sometimes, their recreations are spot on. Have you ever noticed how often that comes up? One thing that TV does get right is heart attacks. But it is a great rainy day afternoon movie if you wanna reminisce about the 90s. What disease were they even shooting for? S: Where Elizabeth Shue’s character has to take a medication every day otherwise she will die of congenital heart disease Take for example one of the key premises of the classic movie of the 90’s, the Saint And to my credit, sometimes their recreations are spot on. J: Yeah, well it’s very dramatic and symbolic… but to be fair, it’s also very common. Have you noticed how often that comes up? S: Well one thing that TV usually does get right is heart attacks. J: Don’t worry guys, I always take it with a grain of salt, and we did go to med school. J: Yeah, I’m embarrassed by how much medicine I’ve learned from TV ads or Scrubs. S: Movies, TV, and music have influenced more of what I think I know than I’d like to admit. Alternatively, you can break the TIMI score down to just risk of MI and death.How does their cardiologist decide that they now warrant going to the cath lab? That’s a subjective decision, but the TIMI study included it as a hard outcome. If their troponin is still negative, so they technically still have UA and nothing worse. For example, a low risk patient with unstable angina comes back in 14 days with chest pain.Because this decision is based on clinical symptoms and possibly EKG findings alone, it’s a subjective diagnosis. It’s a category for patients presenting with symptoms concerning for ACS who don’t meet criteria for myocardial infarction because their troponin is negative, but were taken to the cath lab anyway. Urgent revascularization is synonymous with unstable angina.However “MACE” is a composite score including death, myocardial infarction, or urgent revascularization, a problematic combination of outcomes.We’ve chosen to focus on the TIMI score, which calculates risk of major adverse cardiac events, or MACE, at 14 days.To figure out which patients are at this higher risk, risk stratification tools can help us (because you just can’t catheterize everyone). The highest risk subset of unstable angina patients, specifically those with chest pain at rest, carry a risk of MI or death of up to 25%.Atypical symptoms are also more common in diabetics, the elderly, and women. It’s actually fairly common in patients with MI! In one study, up to 20% of patients with atypical chest pain symptoms were found to have ACS. Atypical chest pain doesn’t exclude ACS.Cardiac biomarkers are negative in UA and positive in NSTEMI. The difference between UA and NSTEMI lies in cardiac biomarkers (aka troponin).Both unstable angina (UA) and NSTEMI are characterized by angina pectoris, defined as a sub-sternal chest pain brought on by minimal exertion or occurring at rest and lasting for >10 minutes.14:00 TIMI isn’t perfect – the issues with the score and MACE outcomes.9:42 You can’t just “cath” everyone – risk stratification to identify patients with high mortality risk.5:22 Clinical context matters – angina pectoris, atypical chest pain, and troponins.4:08 The basics – what is acute coronary syndrome?.Norma Keller for peer-reviewing this episode! Time Stamps In this 2-part Mind the Gap episode, we explore – and pick apart – everything you thought you knew about unstable angina. ![]()
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