[Music] quickly walk through stable angina now this we've discussed so I'm going to go through this quickly it's substernal chest pain that takes place when please during your exertion is that clear now when there's a exertion understand this pay chest pain may then behave like the patient's having an mi this made then weight it up into the neck jaw so on and so forth only at exercise or exertion provoked by exertion relieved by rest what do you want to do do not tell your patient and go away you induce the stress with your patient let it be either physical or chemical when you do so then you find a change in your st now for your exam what you're looking for is the ST segment think about ST segment close your eyes it's isoelectric after your QRS complex it's usually flat when you induce a stress test in a patient who gives you a history of pain upon exertion you'll have you take your hand and put it on that bar known as your ST ice electric and you pull it down it's going an ST strain or nasty depression is that clear exertion a simple is that you put your patient nitroglycerin why you want to decrease your preload right how do you do that they know dilation they know dilation unstable angina what about this major occlusion by what atherosclerosis why is it that Prince metal well we don't really even call that Prince metals to get away from that we don't even really call it variant the most appropriate name for Prince metal and which isn't here it's called vasospasm angina is that clear and actually has nothing to do with that there's grossest hence we don't find it here huh but we move from stable angina into unstable angina what are we headed crescendo o crescendo to whom myocardial function chest even at rest and considered an MI precursor I told you earlier crescendoing towards an MI so therefore you might find a non-stemi which means an ST depression but will you find a cardiac enzyme to be elevated in unstable angina no you will not when we discussed it earlier what is the gold standard cardiac enzyme troponin I and I'll show you why unstable angina once again the pain exactly as to what you expect dis niet rest pain usually pay attention last about 30 minutes relief with rest or nitroglycerin what depends on the occlusion hopefully that'll take care of it but remember you want to become more and more aggressive especially as you get into unstable angina you start thinking about well what do I need to do to bust that clot right okay so let's take a look at the changes on an EKG that is very important for us to understand now let's begin at the top stable angina we know our patient Haydock a pain when upon exertion the patient comes in you do a EKG at rest are you going to find a change yes or no no good you induce stress what then happens you find ST changes what kind take a look at v4 v5 and v6 you tell me where you are v4 v5 v6 medial side of the heart apical side of the heart or is it more lateral I want you to focus on v5 v6 okay v5 v6 will be out here by your armpit is that clear left side but the lateral side of the heart what kind of coronary artery much you be thinking about please don't tell me right all right this is your left circumflex isn't it all right lateral side of the heart and you're most likely coronary artery to be affected there will be a left circumflex I hope that is clear what kind of change you find here you see that ST segment is it flat no especially take a look at v5 v6 you see you find an ST depression don't you so you find ST depression especially with the stress test and then you have end with what about cardiac enzymes elevated or normal normal good nice job so ST segment depression what you're seeing there inverted T wave serum cardiac enzymes negative once again you tell me gold standard cardiac enzyme does sound like a broken record yet I hope so I'm actually doing that on purpose troponin I hear it is once again in terms of what we just completed and we complete a discussion of stable angina we looked at unstable angina and all that I've given you at this point is a simple a few simple procedures that is going to help you distinguish one from the other stable angina relief with rest unstable angina pain at rest difference between unstable and my accordion fraction negative cardiac enzymes with unstable angina good [Music]