Cardiac - CAD/IHD Flashcards
Compare stable and unstable angina
CAD causes
Define risk factors of coronary artery disease
Signs of risk factors
□ Modifiable: abdominal obesity, BP, cholesterol, cigarette smoking, alcohol, diet, DM, lack of exercise, cocaine abuse
□ Non-modifiable: family Hx of CVD, male gender, advanced age
Signs:
BP: >15mmHg arm BP disparity
> 30 BMI
Lipid
- Cutaneous xanthomas, xanthelesma, corneal arcus
DM:
- acathosis nigricans, skin tags
Others:
- Franks sing (ear lobe crease)
- Tar stains, teeth stains
- Wheezing, prolonged expiration (COPD)
Stable angina
Clinical presentation
Associated non-chest pain manifestations of myocardial ischemia
Dyspnea:
rest or exertional
Paroxysmal nocturnal dyspnea
Abdomen:
Atypical, sharp pain
RUQ pain (mimic pancreatitis or gallbladder disease)
Nausea and vomiting
Psychologial:
- Intense Fear
Diaphoresis
Weakness, syncope, coma
Atypical angina features
Stable angina
P/E
Clinical grading of angina pectoralis
CCS grading of angina pectoralis
0 – asymptomatic
I – angina with strenuous exertion
II – angina with moderate exertion
(slight limitation of ordinary activities)
III – angina with mild exertion
(great limitation) → indicated for Tx
IV – angina at rest
Non-invasive assessment of CAD
Indications
Modalities
Indications
o Diagnosis of stable ischemic heart disease (NOT for AMI)
o Risk stratification after acute coronary syndrome (ACS)
o Evaluate exercise tolerance
o Localization of ischemia
Investigations:
Blood tests
12-lead ECG, Echocardiogram
CXR
Stress testing
* Exercise tolerance test + ECG/ Imaging
* Pharmacological stress test with Adenosine or Dobutamine
Imaging:
- SPECT scan
- Cardiac MRI
- Multidetector row computed tomography scan (MDCT) for coronary artery calcium (CAC) score
- Coronary CT/ MR angiography (CTA/ MRA)
blood test metrics for suspected coronary artery disease
Blood:
* CBC
* Thyroid function test
* Fasting glucose, HbA1c, OGTT > DM
* Fasting lipid profile > Hyperlipidaemia
* RFT/ Creatinine (prognostic)
* LFT, CK (statin)
Markers:
* High-sensitivity C-reactive proteins
* Brain natriuretic peptide (BNP)
* hs- TNT
selection process of diagnostic investigations for suspected coronary artery disease
Contraindicated for stress testing / Clinical findings warrant coronary imaging» CT Coronary angiography
No contraindication for stress testing + unable to exercise» Pharmacological stress test
No contraindication for stress test + able to exercise» Exercise stress test
No contraindication for stress test + able to exercise + no previous revascularization/ resting ECG normal» Exercise tolerance test with ECG
2,3,4 may require follow-up coronary imaging if high risk or inadequate information for diagnosis
Exerise stress test
Procedure
Protocol
Target HR
Abnormal results
Pharmacological stress test
Indication
Drugs
SPECT/ rMPI scan
MoA
Procedure
Evaluated metrics
Abnormal results
Cardiac MRI
Indication
Function
Multidetector row computed tomography scan (MDCT) for coronary artery calcium (CAC) score
Indication
Function
CT/ MR coronary angiogram
Indication
Contraindication
Function
Direct indications for coronary angiogram
* Unacceptable angina despite medical therapy
* Non-invasive test results with high-risk features
* Angina or risk of CAF with depressed LVEF
* Unclear non-invasive test results and prognosis
Invasive coronary angiography
Indications
CAD
Poor prognostic factors
Mechanism of silent myocardial ischaemia
Long term diabetes
> Reduced nerve growth factor
> failed development of cardiac sensory system
> failed afferent signal to thoracic ganglia and impulse convergence with somatic nerve fibers
> no chest pain
Non-cardiac causes of IHD
Decrease oxygen delivery - hypoxemia
- Anemia, Sickle cell disease, carbon monoxide poisoning
Endocrine
- Hyperthyroidism (thyrotoxic AF), Pheochromocytoma
Stable CAD
Treatment protocol
5 principles of management of IHD
* Patient education and decision making
* Manage comorbid conditions
* Aggressive modification of preventable risk factors
* Pharmacological management
* Revascularization surgery: PCI, CABG
Coronary revascularization in stable CAD
Indications
CABG vs PCI
Comparison in outcome
Comparison between PCI and CABG
o CABG is superior to PCI in reducing the need for repeat revascularization and increases rate of freedom from angina in patients with severe CAD BUT is associated with a higher risk of stroke
o CABG is preferred over PCI in patients with DM
CABG
Approach
Conduits
Indications for CABG over PCI
Two vessel disease and proximal LAD lesion
Triple vessel disease
Unprotected left main coronary artery disease
CVD prevention in patients with diagnosed atherosclerotic cardiovascular disease (4)
LDL-C >50% reduction and <1.8mmol/L
SBP <140 - 130 mmHg
Antithrombotic therapy
Stop smoking and lifestyle recommendations
Outline 6 classes of lipid modifying therapies proven to reduce CVD
Statins (1st line, most effective in lowering LDL-C and non-HDL-C)
Cholesterol absorption inhibitors e.g. Ezetimibe (2nd line)
PCSK9 inhibitors (3rd line)
Bile acid sequestrants
Long-chain omega-3 fatty acids
antisense oligonucleotide inhibitor of apolipoprotein B (for familial hypercholesterolemia ONLY)
List classes of drugs for prognostic improvement of IHD
Antiplatelets/ anticoagulants
Statins/ lipid modifying drugs: in all patients regardless of LDL, first line
± ACEI only in those with HTN, LVEF ≤40%, DM/CKD
± ARB only in those with SIHD, HTN, DM, Poor LVEF and refractory to ACEI
Differences and similarities between Amlodipine, Nifedipine, Diltiazem and Verapamil action on heart (different CCBs)
Amlodipine and Nifedipine: (for low basal HR)
* Increase HR
* No effects on SA and AV node conduction
Diltiazem and Verapamil: (for tachycardia)
* Decrease HR
* Decrease SA and AV node conduction
ALL:
* Decrease myocardial contractility
* Increase neurohormonal activation
* Increase vascular dilation
* Increase coronary flow
Beta-blocker for IHD
Indications
Contraindications
S/E
Indication:
* First-line monotherapy or combination with CCB or nitrate to decrease angina
* Systolic LV failure (LVEF < 40%) and past-MI
* Ventricular rate control in A-fib
Side effects:
- Bradycardia, syncope, hypotension, bronchial spasm
Contraindications: (electrical and veqssel problems)
* AV block, sinus node dysfunction
* Bronchial asthma (vasocontriction)
* Vasospasm angina, PAD, Raynaud’s phenomenon
* Depression
CCB for IHD
Indications
Contraindications
S/E
Indications:
* Monotherapy if refractory/ intolerant to B-blocker
* Combination with B-blocker or nitrates to decrease angina
* Vasospasm angina ** (B-blocker C/O)**
* Ventricular rate control in A-fib
Side effects:
* Bradycardia (non-DHP CCBs)
* syncope, hypotension, peripheral edema, headache, dizziness, constipation
C/O:
AV block, Heart failure, sinus node dysfunction
Nitrate for IHD
Indications
Contraindications
S/E
Indication:
* Relieve acute anginal pain
* Prophylaxis to increase exercise tolerance and prevent exercise-induced ischaemia
* Long-acting nitrate to decrease angina
Side effects:
- Hypotension, syncope, tachycardia, headache
C/O:
* HOCM
* Same-day use with Selective Phosphodiesterase Inhibitors (PDE-5) e.g. Sildenafil
* SBP <90mmHg/ Severe hypotension
List 4 novel agents for use in IHD
Ivabradine (funny current blocker, decrease HR and myocardial oxygen consumption)
Ranolazine (reduce Ca overload, anti-arrhythmic)
Trimetazidine (Increase energy for myocardial contraction)
Nicorandil (dilation of coronary resistance arterioles and vasodilation)
