2- coronary heart disease overview

Question 1

what familial trait identifies with sudden ischaemic heart disease death?

Answer 1

long QT interval - associated with sudden cardiac death in ischaemic heart disease

Question 2

what is cardiogenic shock?

Answer 2

• inadequate systemic perfusion as a result of cardiac dysfunction
• if untreated = 90% chance mortality

Question 3

what can cause cardiogenic shock?

Answer 3

• acute MI = multivessel disease, particularly occluded LAD
• mechanical complications like VSD (ventricular septal defect), MR (mitral regurgitation), rupture (of muscle)

Question 4

what is type 2 MI?

Answer 4

• associated with death - NOT caused by acute event in coronary arteries like atherosclerotic plaque
• associated with lack of oxygen
• elevated troponin is associated with lack of O2, release during another illness - no evidence of recent plaque rupture
• symptoms of MI, abnormal ECG
  
  • if only troponin then myocardial injury
• risks relate to their other condition

Question 5

what is troponin?

Answer 5

group of proteins found in skeletal and cardiac muscle fibers

(calciumis released and binds to troponin, a regulatory protein associated with actin. This binding causes a conformational change in troponin, which exposes binding sites on actin for myosin

Question 6

is angina a clinical diagnosis?

Answer 6

yes

Question 7

how can tests help coronary disease?

Answer 7

tests can suggest or confirm the presence of coronary disease

Question 8

can people have coronary disease without angina?

Answer 8

yes

Question 9

what can make clinical diagnosis of angina?

Answer 9

visceral pain from myocardial hypoxia = hard to described, often use gestures (pressing, squeezing, heaviness, weight, radiating)

characteristic patterns = provocation (exertion, stress, cold, after meals) , relief (by rest) & timing (only a few mins)

characteristic background = age, gender, smoking etc

Question 10

what are different diagnosis of chest pain?

Answer 10

• GI tract
• musculoskeletal
• pericarditis
• pleuritic pain

Question 11

what is GI tract differential diagnosis of chest pain?

Answer 11

• reflux, burning, acid, waterbrush, provoked by food
• peptic ulcer pain - epigastric, boring, point of finger gesture, relief by antacids/food
• oesophageal spasm
• biliary colic

Question 12

what is musculoskeletal differential diagnosis of chest pain?

Answer 12

• injury - location, tender, prolonged, exacerbates by moving area
• nerve root pain, character, prolonged

Question 13

what is pericarditis differential diagnosis of chest pain?

Answer 13

• central - posture related (relieved by sitting forward)

Question 14

what is pleuritic pain differential diagnosis of chest pain?

Answer 14

focal - exacerbated by breathing, sharp, catching

Question 15

what would be clinical presentation of MI?

Answer 15

• severe, associated autonomic upset
• ongoing pain, despite >10mg morphine

Question 16

what would clinical presentation of pulmonary embolism?

Answer 16

breathlessness, dull (maybe pleuritic)

Question 17

what is the main thing that helps you diagnose angina?

Answer 17

the history - tests help you rule in or rule out

Question 18

what is presentation of dissection of aorta?

Answer 18

tearing, excruciating, severe then eases

Question 19

when is risk stratification tests less helpful?

Answer 19

• high risk (risk of false negative result)
• low risk (risk of false positive result)

Question 20

what are the pros of exercise testing?

Answer 20

cheap, reproducible, risk stratification (positive test at low workload implies poor prognosis)

Question 21

what is risk stratification?

Answer 21

the process of categorizing individuals or populations based on their likelihood or risk of developing a particular health condition, experiencing specific events, or responding to certain treatments

Question 22

is risk stratification good or bad for testing?

Answer 22

good = valuable because it allows healthcare providers to distinguish individuals based on their health risks. This process helps in identifying those who may be at a higher risk of developing specific health conditions or experiencing adverse outcomes

Question 23

what are cons of exercise testing?

Answer 23

poor diagnostic accuracy in important sub groups (female), submaximal tests (exercise or physiological tests that do not require an individual to exert maximum effort)

Question 24

what is perfusion imaging?

Answer 24

imaging that provides info about blood flow to tissues & organs

Question 25

what are the pros of perfusion imaging?

Answer 25

non invasive, pharmacological stress in less mobile patients, more precise than exercise tolerance test, risk stratification

Question 26

what are the cons of perfusion imaging?

Answer 26

radiation, false positives & negatives

Question 27

what is CT angiography?

Answer 27

computer technology used to visualise blood vessels in body

Question 28

what are pros of CT angiography?

Answer 28

non invasive, anatomical data, risk stratification

Question 29

what are cons of CT angiography?

Answer 29

radiation, less precise than angiography particularly when calcium present, cost

Question 30

what is the gold standard test?

Answer 30

angiography

Question 31

what happens in angiography?

Answer 31

• Sheath inserted into artery
• Catheter advanced from wrist / groin to coronary ostium
• X-ray contrast agent injected to outline coronaries
• Video fluoroscopy recorded images in multiple views

Question 32

what are pros of angiography?

Answer 32

• “Gold standard”
• Anatomical and risk stratification
• Follow-on angioplasty

Question 33

what are cons of angiography?

Answer 33

• Risk 1:1000 death, stroke
• Radiation
• Contrast: renal dysfunction, rash, nausea

Question 34

what questions should you ask yourself when trying to identify what test for your patient?

Answer 34

are we trying to rule in or rule out?

how likely are they to have ischaemic heart disease? (use reverend bayes theorem)