Cardiac - CAD/IHD Flashcards by Max Kam

Compare stable and unstable angina

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CAD causes

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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)

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Stable angina

Clinical presentation

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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

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Atypical angina features

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Stable angina

P/E

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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

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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)

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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

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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

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Exerise stress test

Procedure
Protocol
Target HR
Abnormal results

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Pharmacological stress test

Indication
Drugs

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SPECT/ rMPI scan

MoA
Procedure
Evaluated metrics
Abnormal results

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Cardiac MRI

Indication
Function

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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)