Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Medicine (Year 5) > Cardiology (Ischaemic heart disease) > Flashcards

Cardiology (Ischaemic heart disease) Flashcards

1
Q

QRISK

A

Calculates a 10-year estimated risk of developing a cardiovascular disease (CVD, angina, myocardial infarction, stroke, TIA, or peripheral arterial disease). It is expressed as a percentage

For example, if someone’s QRISK score is 30%, this means they have a 30% chance (3 in 10) that they will develop a cardiovascular disease.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

primary prevention depending on QIRISK score

A

Primary prevention involves reducing the risk of CVD in people who have never had CVD.

Patients with a QRISK score ≥10% should be offered a statin.

Management

  • Atorvastatin 20 mg is offered first-line.
  • For patients ≥85 years old, consider offering atorvastatin (as these patients are not included in QRISK assessments).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

patients with which conditions should be offered statins as primary prevention

A

Type 1 diabetes mellitus
Chronic kidney disease (CKD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Secondary prevention

A

Involves treatment after a diagnosis of CVD to reduce the risk of further cardiovascular events (such as myocardial infarction or stroke). It depends on the specific condition.

All patients with CVD should be given a statin in the absence of any contraindication.

Atorvastatin 80 mg is first-line.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

monitoring of statin use

A

Patients taking statins are followed up at 3 months where a lipid profile and liver function tests (LFTs) are measured.

  • If non-HDL cholesterol has not fallen by at least 40%, discuss adherence and lifestyle changes and consider increasing the dose to 80 mg.
  • Statins can cause a transient increase in AST and ALT during the first few weeks of use. They do not need to be stopped if the increase is <3 times the upper limit of normal.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

angina pathophysiology

A

Angina describes chest pain or discomfort in the chest, neck, shoulders, jaw, or arms due to an insufficient blood supply to the heart muscle. It is usually caused by atherosclerosis – where arteries are narrowed due to fatty plaques. Angina can also be caused by valvular disease, hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

stable angina

A

Angina is said to be stable if it occurs predictably with physical exertion or emotional stress, does not last for more than 10 minutes, and is relieved with rest and the use of sublingual nitrates.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Unstable angina

A

describes a sudden worsening in angina occurring at rest and requires immediate hospital admission. It should be managed as a form of acute coronary syndrome.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

stable angina is not

A

an acute coronary syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

angina risk factors

A

Risk Factors

  • Increased age
  • Smoking
  • Hypertension
  • Elevated LDL cholesterol
  • Diabetes mellitus
  • Obesity
  • Illicit drug use
  • Inactivity
  • Male sex
  • Cardiac abnormalities e.g. aortic stenosis/hypertrophic obstructive cardiomyopathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

The typical presentation of angina has 3 characteristics:

A
  • The pain is crushing or squeezing (may be central and may radiate to the jaw or arms)
  • The pain is provoked by exercise or emotional stress
  • The pain is relieved by rest or using glyceryl trinitrate (GTN)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Atypical angina

A

has only 2 of the 3 features, meaning they may not have any chest pain at all. It is usually seen in:

Women
People with diabetes
The elderly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

when does angina become acute coronary syndrome

A
  • Chest pain is not relieved with rest and is not relieved with GTN spray
  • Shortness of breath, nausea and vomiting, sweating, and palpitations may occur
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

investigations for angina

A
  • resting ECG
  • Hb
  • lipid profile
  • HbA1c
  • CT coronary angiogram
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

management of angina

A
  • aspirin
  • statin
  • sublingual GTN spray
  • a drug to provide long term relief
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Long-term relief of anginal symptoms

A

1st-line: beta-blockers or calcium channel blockers (CCBs)

  • Beta-blocker options: bisoprolol, atenolol carvedilol, metoprolol
  • Calcium channel blocker options:
    If monotherapy then rate-limiting CCBs: verapamil or diltiazem
  • If combined with beta-blockers: nifedipine or amlodipine
    Never combine beta-blockers with rate-limiting calcium channel blockers (such as verapamil and diltiazem). This can cause severe bradycardia due to heart block

2nd-line:

  • if poor response to initial treatment then medication should be increased to the maximum tolerated dose e.g. atenolol 100mg od
  • if one fails to work, try the other or switch to a combination

3rd-line: depends on what the patient is taking

  • If the patient is taking monotherapy (beta-blocker/CCB) and cannot tolerate addition of another 1st-line drug: offer one of the other anti-anginal drugs (discussed below)
  • If the patient is taking both a beta-blocker and CCB, refer for revascularisation via percutaneous coronary intervention (PCI) or a coronary artery bypass graft (CABG) and offer one of the other anti-anginal drugs (discussed below)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Other anti-anginal drugs
if first and second line fail

A
  • Long-acting nitrates e.g. isosorbide mononitrate
  • Ivabradine
20
Q

How should Long-acting nitrates e.g. isosorbide mononitrate be prescribed

A
  • Some patients develop nitrate tolerance, meaning their symptoms return and treatment is less effective. To overcome this, the dosing intervals should be asymmetrical.
  • This effect is not seen in people who take once-daily modified-release isosorbide mononitrate
21
Q

how do nitrates work

A

Nitrates are drugs that have vasodilating effects. They are mainly used in the management of angina and heart failure. They work by activating guanylate cyclase which converts GTP to cGMP which reduces intracellular calcium ion levels and vasodilation.

Examples of nitrates are:

  • Sublingual glyceryl trinitrate (GTN spray): used to abort acute angina attacks
  • Isosorbide mononitrate: for the prophylaxis of angina

Key side effects of nitrates are:

  • Headaches
  • Tachycardia
  • Flushing
  • Hypotension
22
Q

Contraindications to nitrates include:

A
  • Aortic stenosis
  • Cardiac tamponade
  • Hypertrophic cardiomyopathy
  • Hypotension
  • Hypovolaemia
  • Constrictive pericarditis
  • Increased intracranial pressure secondary to pulmonary oedema
23
Q

acute coronary syndrome symptoms occur due to

A

ischaemia in the myocardium

24
Q

acute coronary syndrome is an umbrella term for

A
  • ST-elevation myocardial infarction (STEMI)
  • Non-ST-elevation myocardial infarction (NSTEMI)
  • Unstable angina

NOT STABLE ANGINA

25
Q

presentation of ACS

A

The main presenting complaint is chest pain:

  • Usually retrosternal, crushing, central, heavy, severe, and diffuse
  • Sometimes patients describe pressing or squeezing
  • May radiate to the left arm or jaw
  • Some patients may not have pain at all e.g. diabetics, elderly people, female sex
  • Sometimes they may have atypical pain:
  • They may describe it as:
  • Indigestion
  • Epigastric pain
  • Interscapular pain in the back
  • Neck or jaw pain

Other associated features:

  • Dyspnoea
  • Pallor
  • Sweating
  • Nausea and vomiting
  • Anxiety and distress
  • Palpitations
26
Q

investigations for ACS

A

12-lead ECG:
* Additional leads should be recorded if the standard leads are inconclusive or the patient has signs or symptoms of ongoing myocardial ischaemia

Cardiac troponins:
* if this does not delay treatment of a STEMI
* This can confirm the diagnosis, but an ECG alone can suffice

27
Q

diagnosing a STEMI

A

STEMI is only diagnosed if there are ECG changes.

Cardiac troponins can be used to confirm the diagnosis but should not delay treatment

  • ST-elevation in at least 2 contiguous leads:
    ≥2.5mm in men <40 years old
    ≥2mm in men >40 years old
    ≥1.5mm in women of all ages
  • A new left bundle branch block
  • ST depression in V1-V3 suggests a posterior STEMI
28
Q

Non-ST-Elevation Myocardial Infarction (NSTEMI)

A

NSTEMI is diagnosed using an ECG and cardiac troponins:

  • No ST-elevation may be seen
  • ST depression – worse prognosis
  • T wave inversion
  • Troponins are raised
29
Q

Unstable Angina findings

A
  • ECG may be normal
  • Troponins are not raised
30
Q

initial management of all ACS

A

MONA

  • Loading dose of aspirin 300 mg immediately
  • Oxygen only if saturations are <94%
  • Morphine only if severe pain is present
  • Nitrates may be given if there is ongoing chest pain or hypertension-caution if the patient is hypotensive.
31
Q

management of STEMI

A

Options: PCI or fibrinolysis

Percutanesous coronary intervention (PCI) is offered if patient presents<12hrs

  • patient should be offered praugrel with aspirin pre treatment

Fibrinolysis if patient presents within 12 hours of symptoms but PCI is not possible within 120 minutes

  • patient should be offered antithrombin drug e.g. LMWH, fondaprinux
  • ECG should be performed 60-90 minutes after thrombolysis - if still evidence of ST elevation, offer immediate coronary angiography annd PCI do not repeat fibrinolysis
32
Q

management of NSTEMI depends on

A

GRACE score

Global Registry of Acute Coronary Events (GRACE) score is calculated which then guides treatment. This calculates the risk of mortality within the next 6 months

33
Q

NSTEMI : GRACE score <3% (low risk)

A

Medical management:

  • Dual antiplatelet: ticagrelor and aspirin + fondaparinux
  • If high-bleeding risk: clopidogrel and aspirin or aspirin alone
  • If ischaemia develops or is shown on testing: angiography with PCI

if hypotensive dont give nitrate

34
Q

NSTEMI : GRACE score >3% (intermediate- high risk)

A

PCI within 72 hours if stable, immediately if unstable

35
Q

after treament of ACS, all patients should have

A
  • Echocardiogram to assess left ventricular function.
  • Establish secondary prevention after an acute MI:
36
Q

secondary prevention after an acute MI:

A

People after an acute MI should be offered an

  • Ramipril-angiotensin-converting enzyme (ACE) inhibitor
  • aspirin
  • clopidogrel - another antiplatelet for 12 months
  • a beta-blocker
  • statin.
37
Q

Absolute contraindications to fibrinolysis

A
  • History of intracranial haemorrhage at any time
  • History of haemorrhagic stroke at any time
  • Ischaemic stroke in the last 6 months
  • Major surgery/trauma in the last 1 month
  • Gastrointestinal bleeding within the last 1 month
  • Bleeding disorders
  • Aortic dissection
  • Non-compressible punctures within the last 24 hours e.g. liver biopsy/lumbar puncture
  • Central nervous system neoplasm or arteriovenous malformation
38
Q

driving guidance after ACS

A

Stop driving for:
* 1 week if they had successful treatment
* 4 weeks if treatment was not successful
* 4 weeks if they were managed medically
They do not need to tell the DVLA

39
Q

complications of MI

A
  • Cardiac arrest
  • Chronic heart failure
  • Cardiogenic shock e.g. papillary muscle rupture, ventricular septal rupture
  • Acute pericarditis
  • Dressler syndrome
  • Left ventricular aneurysm
  • Left ventiruclar free wall rupture and pericardial tamponade
  • Ventricular septal defect
  • Acute mitral regurgitation
40
Q

Acute pericarditis

A

Usually occurs within 48 hours of a myocardial infarction. Patients have pleuritic chest pain that’s relieved when leaning forward/sitting up and worsened lying down

41
Q

Dressler’s syndrome

A

immune mediate seocndary pericarditis
- Usually occurs 2-6 weeks after an MI. Patients have fever, pleuritic chest pain, raised ESR, and pericardial effusions.
- It is managed with aspirin or NSAIDs

42
Q

Patients may develop tolerance to this medication necessitating a change in dosing regime

A

Isosorbide mononitrate

43
Q

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications

A

The correct answer is: Bisoprolol

Aspirin and simvastatin should also be prescribed, but they are not anti-anginals.

Verapamil should be avoided in patients with known heart failure.

44
Q

Is contraindicated if a patient is already prescribed atenolol
.

A

The correct answer is: Verapamil

This would risk complete heart block

45
Q

criteria for STEMI

A
  • 1mm ST segment elevation in 2 contigious limb leads
  • 2mm ST segment elevation in 2 contigious chest leads
  • new LBBB

Medicine (Year 5) (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions