Atheroma and vascular disease Flashcards
- =12 lead ECG
ECG is normal, what is likely to reveal the problem?
- =repeat ECG with exercise
- Image coronary arteries with a coronary angiogram which will show blockage if they are there (invasive)
- Troponin is used in patients with damage to myocardium but he only gets it at rest
Get him on treadmill and start walking, as he speeds up, he will say he has chest pain: ECG when walking
Clock 1-shows how long he has been walking for
At rest he has a slower heart rate (below 100)
Anterolateral ST depression (left coronary artery is partly blocked) and tachycardia
Look at ST being lower than PR segment
ST depression persists after exercise before they slowly recover, which means it is proper ST depression
=Angina
Chronic Stable Angina:
Acidosis in myocardium causes ST depression
List 4 useful drugs for chronic stable angina
- Beta blockers
- Aspirin
- GTN and slow release form (problem with slow release is that you acclimatise to them so this is why it is in brackets)
- Statins
ACE inhibitor is incorrect but is used in heart failure. This guy has only got a blocked artery as a problem, the heart hasn’t died yet.
Chronic stable angina treatment:
CABG-use vein from leg if really bad
Angioplasty used before they have a heart attack
LCA-supplies anterior wall and if it goes round the side to V6 you have an anterolateral block.
This patient at rest is fine but on exertion, not enough blood can get through.
Get dying muscle beyond blocked coronary artery so you need to prevent muscle from dying
What does this ECG show?
Shows anterior ST elevation MI in V2 and V3 which is in the front of the heart.
This means the patient is currently infarcting, and the patient will have chest pain at rest
If left the heart muscle will die and his heart will no longer contract and his blood pressure will drop and he will go into long term heart failure. Or he may die from ventricular fibrillation (shock them if so).
Inferior ST elevation MI
2, 3 and AVF are the inferior wall of the heart
So right coronary artery is blocked
What is the difference in managing a heart attack vs angina?
- Time-if having a heart attack, need rapid intervention to unblock coronary artery to prevent muscle damage
- Immediate angiogram and immediate angioplasty
- If end up in smaller hospital will be given thrombolysis drug with tPA. Problem is people bleed after as it turns off all their clotting factors and they have to be watched closely, but same outcome
- When they arrive and you are waiting, start aspirin, nitrates and beta blockers. (may as well give a statin too)
- If you slow the heart down there will be less ischaemia.
- PCI=angioplasty with a stent
Managing cardiovascular risk:
The combination of coronary angioplasty with stenting is usually referred to as percutaneous coronary intervention (PCI).
Need to learn the treatment for hypertension
Start with ACE inhibitor unless they are over 55 or they are black.
If A or C doesn’t work, then you give both to either.
Then add thiazide diuretic
Otherwise get expert help
=Give thiazide on top of beta blocker in people who have had a heart attack.
Less heart attacks in intensive group than standard group with beta blocker alone.
Conclusion is that you need to really push the blood pressure down.
Optimal medical therapy after heart attack
=Give thiazide on top of beta blocker in people who have had a heart attack.
PCSK9 inhibitor
eg Evolocumab
Makes cholesterol fall further
Previous cholesterol was 3.1
This Evolocumab is very expensive
Evolocumab dropped the risk of heart disease and stroke BUT the risk of death is now different
Used to treat severe forms of inherited hypercholesterolaemia.
