Angina, IHD and ACS

Question 1

Cause of IHD

Answer 1

Limit of blood supply to the myocardium

Question 2

Risk factors of IHD

Answer 2

Hypertension, Diabetes, Family History, Hyperlipidaemia, Sedentary Lifestyle, Alcohol and Smoking

Question 3

Contents of atherosclerotic plaque:

Answer 3

Lipid, Necrotic Core, Connective Tissue and Fibrous ‘Cap’

Question 4

Stages of atherosclerosis formation:

Answer 4

1. Injury to endothelial cells
2. Endothelial dysfunction
3. Chemoattractants released
4. leukocytes migrate into the vessel wall
5. Fatty Streaks (aggregations of lipid-laden macrophages and T lymphocytes within the intimal layer)
6. Fibrous plaques/advanced lesions (impede blood flow and prone to rupture)
7. Plaque rupture (Balance shifts - cap becomes weak - plaque ruptures)

Question 5

Types of angina

Answer 5

Stable Angina
Unstable Angina
Decubitus Angina
Variant (prinzmetal) Angina

Question 6

Pathophysiology of Angina

Answer 6

• A consequence of restricted coronary blood flow
• O2 supply-demand mismatch
• Impairment of blood flow
• Increased distal resistance
• Electro-hydraulic analogy

Question 7

Epidemiology of Angina

Answer 7

Men - 5%

Women - 4%

Question 8

Causes of Angina

Answer 8

Most Common: Atheroma

Rarer Causes: Anaemia, coronary artery spasm, AS, tachyarrhythmias, arteritis/small vessel disease

Question 9

Signs of Angina

Answer 9

Levine’s sign: clenched fist over chest

Question 10

Clinical presentation of angina (3 points)

Answer 10

1. constricting/heavy discomfort - in the chest, jaw, arms or shoulders
2. symptoms are brought on by exertion
3. symptoms are relieved by rest or GTN spray

Question 11

Investigations for angina and what would expect to see

Answer 11

12 Lead ECG - ST elevation/depression
- Flat/inverted T waves
- Signs of past MI
Bloods, echo, chest x-ray
Further investigations: Exercise EEG, angiography and functional imaging

Question 12

Precipitating factors for angina

Answer 12

Demand - emotion, cold weather, heavy meals
Others - HTN, tachyarrhythmia
Supply - Anaemia, hypoxia, polycythaemia, hypothermia

Question 13

Features that make angina unlikely (2 points)

Answer 13

• Pain that is continuous pleuritic or worse on swallowing

- Pain that is associated with palpitations, dizziness or tingling

Question 14

Name 3 ways to modify the risk factors for someone with angina

Answer 14

1. Stop smoking
2. Exercise
3. Weight loss

Question 15

4 Different secondary preventions of cardiovascular disease

Answer 15

1. Stop smoking, exercise, dietary advice, optimise hypertension and diabetes control (modifying risk factors)
2. 75mg aspirin daily
3. Address hyperlipidemia
4. Consider ACE inhibitors

Question 16

Pharmacological management of angina (There are 5)

Answer 16

1. Aspirin
2. Statins
3. B-blockers (1st line anti-anginal) e.g. bisoprolol/atenolol
4. Glyceryl trinitrate (GTN) spray
5. Calcium channel blockers e.g. verapamil, amlodipine

Question 17

2 Types of acute coronary syndrome

Answer 17

1. Unstable angina

2. Myocardial infarction

Question 18

Pathology of acute coronary syndrome

Answer 18

Plaque rupture -> Thrombosis -> Inflammation

Rarer Causes: Emboli, coronary spasm, vasculitis

Question 19

Definition of unstable angina

Answer 19

• Cardiac chest pain at rest with a crescendo pattern

- New-onset angina

Question 20

Presentation of ACS (3 points)

Answer 20

1. Cardiac chest pain at rest (>20 mins)
2. Cardiac chest pain with a crescendo pattern
3. New-onset angina
   Associated symptoms: Nausea, sweatiness, SOB, palpitations

Question 21

Investigations of ACS (4 points)

Answer 21

1. History
2. ECG
3. Troponin (no significant increase)
4. CXR

Question 22

DDx of ACS

Answer 22

Angina, pericarditis, myocarditis, aortic dissection, PE, reflux

Question 23

What is a STEMI?

Answer 23

Complete occlusion of a coronary artery, full-thickness damage to the heart muscle.
Diagnosed on an ECG.
Pathological Q-wave.

Question 24

What is an N-STEMI?

Answer 24

Partial occlusion of a major CA or full occlusion of a minor CA.
Retrospective diagnosis - after troponin.
Partial-thickness damage

Question 25

Risk factors for an MI?

Answer 25

Age, male, smoking, HTN, DM, hyperlipidemia, family history, obesity/sedentary lifestyle

Question 26

Pathophysiology of an MI

Answer 26

1. Rupture/erosion of fibrous cap 2. platelet aggregation and adhesion, localised thrombosis, vasoconstriction, and distal thrombus embolisation 3. Thrombus formation -> myocardial ischaemia 4. plaque rupture/ fissure and thrombosis 5. MI, ischaemic stroke, critical leg ischaemia or sudden CVS death

Question 27

Symptoms of an MI

Answer 27

``` Acute central chest pain Lasts >20 mins Nausea Sweating SOB Palpitations 'Silent' : Elderly/diabetic ```

Question 28

Signs of an MI

Answer 28

``` Distress Anxiety Pallor Sweatiness Hyper/Hypotension Tachy/Bradycardia 4th heart sound ```

Question 29

How is a troponin assay used?

Answer 29

- 1 Measurement at least 6 hours after the pain started - No elevation: No MI - Elevated: repeat after another 3 hours - Significant rise/fall and other diagnostic factors: MI confirmed

Question 30

What changes would be seen on an ECG of a person with a STEMI? (5 points)

Answer 30

1. ST-elevation 2. Tall T waves 3. LBBB 4. T wave inversion 5. Pathological Q wave

Question 31

What changes would be seen on an ECG of a person with an N-STEMI? (1 Point)

Answer 31

ST depression, T wave inversion

Question 32

What other investigations would be performed to confirm an MI? and what would you expect to see?

Answer 32

Troponin I/T - raised Myoglobin - raised Transthoracic echocardiography

Question 33

Hospital Management of an MI

Answer 33

``` MONA M- Morphine (5-10mg) O- Oxygen (if hypoxic) N- Nitrates e.g. GTN A- Aspirin and clopidogrel ```

Question 34

Pre-hospital management of MI

Answer 34

Aspirin (300mg chewable) GTN (sublingual) Morphine

Question 35

2 Types of coronary revascularisation

Answer 35

1. PCI within 120 mins of medical contact | 2. CABG

Question 36

MI Complications

Answer 36

``` DARTH VADER D- death A- arrhythmias R- ruptured septum T- tamponade H- heart failure ``` ``` V- valve disease A- aneurysm of ventricles D- Dressler's syndrome E- embolism R- reoccurrence of ACS ```