56. Ischemic Heart Disease 52% Flashcards
Describe diagnosis of ischemic heart disease (2)
- Ischemic heart disease diagnosis is based on pretest probability (symptoms, risk, noninvasive testing)
- CAD diagnosis is established if history of ACS or presence of obstructive lesions on angiography
Describe : Classical chest pain (4)
- Dull RSCP (discomfort, heaviness, aching, pressure; not changing in intensity with inspiration, cough or position change; with or without radiation into jaw, neck, shoulders, arms)
- Provoked by exertion or emotional stress (lying down, post-prandially)
- Relieved within <5 min by rest or Nitroglycerin.
- Non-classical symptoms might include: shortness of breath, N/V, diaphoresis, fatigue, dizziness
Which population should we look out for that may present with ATYPICAL chest pain ? (4)
- Women
- Those with DB
- Young
- Those at no risk
Describe : Atypical chest pain in DM, women, patients without risk factors (eg. young) (3)
- New CP
- Duration >20 min
- Occurrence at rest
Name modifiable risk factors (9)
- Smoking
- DLP
- DM2
- CKD
- HTN
- Obesity or Metabolic syndrome
- Physical Inactivity
- Diet
- Depression
Name non-modifiable risk factors (4)
- Age
- Sex (male)
- Ethnicity (Hispanic, Native American, African American, Asian)
- Family history of premature CVD (1st degree relative, <55yo men, <65yo women)
Name CV Co-morbidities (4)
- Maladie valvulaire
- Maladie cérébrovasculaire
- Maladie vasculaire périphérique
- Maladie rénale
Name investigations : Ischemic heart disease (7)
- 12-lead ECG
- Hemoglobin
- Full lipid panel (Total cholesterol, LDL, HDL)
- Fasting blood glucose or HbA1c
- Creatinine
- AST, ALT, Total Bilirubin
- TSH
Name findings consistent with CAD in EKG (5)
- Evidence of left ventricular hypertrophy
- ST-T wave changes consistent with ischemia
- Previous Q-wave myocardial infarction (MI)
- Bundle branch block
- Conduction/rhythm disturbances
Name Choice of non-invasive testing (2)
- Exercise ECG test preferred if able to exercise and interpretable ECG
- Alternatives to exercise include vasodilators and cardiac stimulants
Name invasing testing (1)
L’angiographie coronaire (ou coronarographie)
Name vasodilators agents for non-invsaive testing (3)
- adénosine
- dipyridamole
- régadénoson
Name cardiac stimulants agents for non-invsaive testing (1)
dobutamine
Invasive testing (coronary angiography) indicated if what ? (5)
- High pretest probability of stable ischemic heart disease
- High-risk features on non-invasive testing
- Persistent symptoms or inadequate QOL despite optimal medical treatment
- History of ACS
- Life-threatening arrhythmias
Describe counselling in management of stable disease (9)
- Review treatment options, Medication adherence for symptom relief and prevent disease progression
Explanation of CV risk - Treat any concurrent DM2 or DLP or HTN
- Lifestyle
- Smoking cessation
- Weight loss
- Diet (high intake of vegetables, whole grains, fresh fruit; reduce salt, saturated/trans fat)
- Physical activity (150 min/week of moderate or vigorous activity)
- Assess and manage stress/depression
- Red flags when to seek medical care
Describe tx to improve prognosis in stable disease (4)
- ASA 81mg (or Clopidogrel 75mg if ASA intolerance)
- High-intensity Statin (eg. Rosuvastin 20-40mg daily, Atorvastatin 80mg daily)
- ACEI (or ARB) if HTN, DM2, CKD, left ventricular ejection fraction ≤ 40%
- Revascularization therapy (PCI or CABG) in patients who underwent coronary angiography
Describe symptomatic relief in tx stable disease (2)
- Nitroglycerin (short-acting) 0.4mg SL tab or spray q5 mins PRN, seek prompt medical attention if pain persists after 3 doses
- Beta-blockers especially if prior MI, HF, LVEF ≤ 40%, eg. Bisoprolol, target HR 55-60 bpm
If cannot tolerate BB or symptomatic on monotherapy, what to do ?
start/combine
* Long-acting CCB (eg. Amlodipine or Diltiazem). Avoid non-dihydropyridine CCB in combination with BB if risk of AV block and excessive bradycardia
* Nitroglycerin transdermal patch 0.2mg/hour titrate up to 0.8mg/hour (remember to remove patch 12-14h, eg. apply 8AM-8PM)
Describe what to evaluate during follow-ups
HPI
* Severity and progression of symptoms
* Impact on daily function and QOL, NYHA Class I-IV
* Complications of CAD (arrhythmia, heart failure, ACS)
* Medication compliance, appropriate use of medication (Nitro SL prn)
Physical exam
* Cardio exam (BP, HR, S4, murmur, bruit)
* Resp exam (crackles)
Investigations
* ECG if symptom change or annually
* Routine CBC, creat, FBG/HbA1c, lipids
Management
* Counselling as above
* Optimize medication
* Cardiac rehab program, especially s/p revascularization
Comment confirmer DX si : Si pt capable de faire effort et ECG au repos N
Épreuve d’effort (EE)
Comment confirmer DX si : Si pt pas capable de faire effort ou ECG repos anormal
- Mibi-dypiridamole (BBG ou rythme ventriculaire pmp)
- ou écho- effort
- ou Mibi d’effort
- ou angiographie par TDM
Si EE négatif, est-ce que l’angine est éliminé?
bon facteur pronostic, mais n’élimine pas l’angine
Vrai ou Faux
EE positif avec certains facteurs de mauvais pronostic peuvent justifier coronarographie
Vrai
(ischémie précoce < 3min., ischémie persistante < 3min en récupération, sous décalage SST < 2mm, faible tolérance à l’effort, apparition d’arythmie ventriculaire en récupération)
Nommez C-I EE (11)
- sténose aortique sévère
- HTP sévère
- IM < 2 jours
- angine instable
- instabilité HD
- endocardite
- péricardite
- myocardite
- embolie
- suspicion de dissection aortique
- condition pouvant s’exacerber à l’effort
Contre-indication au Mibi-dipyridomale (5)
- bronchospasme
- BAV haut grade
- sténose artères rénale
- hypoTA
- sick sinus syndrome sévère
Nommez C-I : Angiographie par TDM
si fonction rénale ne permet pas de contraste
Nommez indications de coronarographie (9)
- Histoire de mort subite
- Angor instable
- NSTEMI
- Angor avec insuffisance cardiaque symptomatique
- Occupation nécessitant dx définitif
- Hospitalisations récurrentes pour DRS
- Haute probabilité clinique MCAS sévère
- Examen non invasif suggérant mauvais pronostic
- Angor persistant malgré traitement médical chez patient avec test non invasif de bon pronostic
Décrire comment éduquer le patient sur les raisons de consultations à l’urgence (3)
- ddlr malgré repos < 20min
- angor crescendo ou de novo survenant au moindre effort
- angor avec syncope/dyspnée ou OMI
Nommez les artères atteintes selon les territoires
* Ant
* Lat
* Inf
- Ant : IVA
- Lat : circonflexe
- Inf : coronaire droite
