Cardiology: Ischaemic Heart Disease I

Question 1

How does angina typically present? [4]

Answer 1

Chest pain:
- Left sided
- Tight / squeezing
- Pressure like pain
- Associated SOB
- Radiates down left arm or back

Pain worse with exercise or cold weather

Pain relieved with rest

Pain relieved with GTN

Question 2

Describe what is meant by cresendo angina [1]

Describe the clinical consequence of this [1]

Answer 2

Recent progressive drop in exercise tolerance

Suggests narrowing is getting tighter and vulnerable atherosclerotic plaque may occur

If pain at rest: unstable angina

Question 3

NICE define anginal pain as what? [3]

Answer 3

NICE definition:
1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes

Interpretation:
* Patients with all 3 features have typical angina
* Patients with 2 of the above features have atypical angina
* Patients with 1 or none of the above features have non-anginal chest pain

Question 4

How long does it take for GTN to provide symptomatic relief of angina? [1]

Answer 4

~ 2mins

If more: then not GTN

Question 5

What are the different causes of angina? [3]

Answer 5

Coronary Atherosclerosis
- Predominant cause

Also:
Coronary artery vasospasm:
- Constriction of the coronary arteries, leading to transient ischemia.

Microvascular dysfunction:
- Impaired function of the coronary microvasculature, leading to inadequate blood supply to the myocardium.

Extracoronary factors: which increase myocardial oxygen demand or decrease supply.
- Aortic stenosis
- Aortic regurgitation
- hypertrophic cardiomyopathy
- significant anemia

Question 6

Why does AS and AR cause angina? [1]

Answer 6

Coronary arteries emerge just above the aortic valve: so get impeded blood flow

Question 7

What is the name of this sign when asked for description of chest pain? [1]

Answer 7

Levine’s sign

Question 8

What is decubitus angina? [1]

Answer 8

Form of stable angina where get pain when lying down without any apparent cause

Question 9

What is meant by Prinzmetal’s or variant angina? [1]

Answer 9

When you get transient ST elevation due to coronary vasopasm (artery isn’t blocked, but muscle is in spasm)

Question 10

What is meant by cardiac syndrome X? [1]

Answer 10

St depression on excerise ECG but normal angiogram

Sign of microvascular angina

Question 11

What is meant by St Vincent’s angina? [1]

Answer 11

Not actually angina: pharyngitis due to ulcerative ginigivitis

Question 12

What is the name for this sign of hyperlipdaemia? [1]

Answer 12

corneal arcus lipid deposits that appear as rings on the outer region of the cornea

Question 13

NICE:
What investigations are used to investigate angina? [3]

Answer 13

1st line:
- CTCA (+calcium score)

2nd line:
- Non-invasive functional imaging (looking for reversible myocardial ischaemia)

3rd line:
- Invasive coronary angiography

Question 14

Describe how invasive coronary angiography occurs [3]

Answer 14

A catheter is inserted into the patient’s brachial or femoral artery

Directed through the arterial system to the aorta and the coronary arteries under x-ray guidance

Contrast is injected to visualise the coronary arteries and identify any areas of stenosis using x-ray images

This is considered the gold standard for determining coronary artery disease

Question 15

What function investigations can you conduct for borderline cases of angina / need further investigations? [4]

Answer 15

• Exercise or stress ECHO
• Nuclear medicine: myocardial perfusion scan
  scans use a small amount of radioactive substance to create images which show blood flow to the heart muscle
• Cardiac MRI with stress perfusion
• Exercise ECG

Question 16

What advice do you give when giving GTN spray? [1]

Why? [1]

Answer 16

Can cause dizziness: due to veno-dilatation and BP to drop

Question 17

All patients with angina should be prescirbed which drugs? [2]

Answer 17

Aspirin 75mg (prevent risk of MI)

Statin (reduces cholesterol)

Question 18

Describe the treatment algorithm for stable angina patients [5]

Answer 18

Sublingual glyceryl trinitrate to abort angina attacks

All patients:
- Aspirin 75 mg
- Statin

1st line:
- Beta blocker: e.g. metoprolol
- CCB: e.g. Amlodopine
- If there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
- If a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

2nd line:
- a long-acting nitrate: Isosorbide mononitrate
- ivabradine
- nicorandil
- ranolazine

3rd line:
- CABG
- PCI

Question 19

Beta blockers shouldn’t be prescribed alongside which angina medication? [1]

Why? [1]

Answer 19

Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

Coadministration of verapamil and β-blockers results in additive negative inotropic, chronotropic and dromotropic (conduction properties) effects on the heart.

Question 20

If a CCB is being used as first line tx for stable angia, what type should be used? [1]

Give two examples [2]

Answer 20

If a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used.

Question 21

What do you need to consider about nitrate therapy for stable angina? [1]

How do you modifiy treatment to allow for this? [1]

Answer 21

Nitrate tolerance can occur

The BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness

Question 22

Describe the MoA of ivabradine [1]

Answer 22

pacemaker current inhibitor: slows the HR down (not a Beta blocker)

Question 23

Describe the MoA of ranolizine [1]

Answer 23

Late Na current blocker

Question 24

Nicorandil has a rare AE of ? [1]

Answer 24

GI ulceration

Question 25

How can you remember the drugs used for secondary prevention of stable angina patients? [4]

Answer 25

**4 As:** A – **Aspirin** 75mg once daily A – **Atorvastatin** 80mg once daily A – **ACE** **inhibitor** (if diabetes, hypertension, CKD or heart failure are also present) A – **Already** on a **beta** **blocker** for symptomatic relief

Question 26

Why do you get nausea, anxiety or sweating when have ACS? [1]

Answer 26

Undergoing **adrenaline surge**: Due to severe ischaemia; causes necrosis; negative feedback loop causes huge amount of adrenaline released

Question 27

Describe the pathophysiology of ACS ]3

Answer 27

Myocardial damage secondary to ischaemia Generally occurs after following steps: **Step 1 - endothelial dysfunction** * Endothelial injury causes a local inflammatory response. * If the injury recurs or healing is incomplete, inflammation may continue leading to the accumulation of low-density lipoproteins (**LDL**). * These become **oxidised** by local waste products creating reactive oxygen species (**ROS**). **Step 2 - plaque formation** * In response to these irritants, endothelial cells attract monocytes (**macrophages**). * These engulf (phagocytose) the LDLs swelling to become foam cells and ‘**fatty streaks’.** **Step 3 - plaque rupture** * Continued inflammation triggers **smooth muscle cell migration**. * This forms a **fibrous** **cap**, which together with the fatty streaks, develops into an **atheroma**. * The **top** of the atheroma **forms** a **hard** **plaque**. * This may **rupture** through its **endothelial** **lining** **exposing a collagen-rich cap**. * **Platelets** **aggregate** on this **exposed** **collagen** forming a **thrombus** that may **occlude** or **severely** **narrow** the vessel. * Alternatively, the **thrombus** **may** **break** **lose**, embolising to **infarct a distant vessel.**

Question 28

How do you assess ACS patient? [4]

Answer 28

ABCD **Airway**: - Patent? **Breathing**: - RR? - Saturations? - Pulmonary oedema due to LV impairment can cause hypoxia **Circulation**: - HR - BP **Disability**: - GCS **DONT FORGET GLUCOSE**

Question 29

ACS causing bradycardia can indicate MI in which part of heart? [1] Why? [1]

Answer 29

**Inferior MI** Right coronary artery perfuses the sinoatrial node, heart block and bradycardia may occur

Question 30

go over heart anatomy & SALI

Question 31

What is LDL target for secondary prevention of MI? [1]

Answer 31

< 1.4

Question 32

What are target times for coronary angiography for: STEMI [1] NSTEMI [1]

Answer 32

STEMI: **< 6 hours** NSTEMI: **< 72 hours**

Question 33

In cases of primary PCI, which is the first line P2Y12 inhibitor? [1] Why? [1]

Answer 33

**Ticagrelor**: most rapidly acting

Question 34

What is the difference between myocardial infarction and myocardial injury? [2]

Answer 34

**Myocardial injury** = trop > 99% percentile ULN **Acute MI = Injury +** - Symptoms - ECG changes - Imaging showing loss of viable myocardium - Evidence of coronary aetiology *Implies ischaemia*

Question 35

What are the key differentials for retrosternal chest pain?

Answer 35

**acute coronary syndrome** **angina** **Panice disorder / anxiety** **GORD** **pulmonary embolism** **pericardial effusion** **Costochondritis** - the inflammation of the cartilage that connects a rib to the sternum (breastbone). It can cause localized chest pain that may be aggravated by movement or palpation.

Question 36

Explain to a patient how to take sublingual GTN spray in the event of chest pain [5]

Answer 36

GTN tablets: * **Sit down.** * Put a tablet under your **tongue** and **close your mouth.** * Allow the tablet to **dissolve** slowly – **do not suck, chew or swallow it**. * **Close the container** – this is important, so your tablets do not lose their strength. * Rest for a while, then stand up slowly GTN spray: * **Sit down.** * If you have not used your spray for over a week, **do 1 spray into the air before you use it.** * Hold the nozzle in front of your mouth, with your finger on the button, and take **a deep breath.** * Open your mouth and lift your tongue up. * **Spray the GTN under your tongue** by pressing once firmly. Do not breathe in while you spray. * **Close your mouth immediately.** * **Breathe through your nose keeping your mouth closed.** * **Rest** for a while before you stand up slowly. .

Question 37

When should you call 999 after administering GTN? [3]

Answer 37

**Call 999 if:** you've taken 2 doses of GTN and: * you're still in pain 5 minutes after your 2nd dose * your pain is getting worse * you feel unwell

Question 38

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications? A. Verapamil B. Amlodipine C. Nifedipine D. Bisoprolol E. Nicorandil F. Isosorbide mononitrate

Answer 38

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications? A. Verapamil B. Amlodipine C. Nifedipine **D. Bisoprolol** E. Nicorandil F. Isosorbide mononitrate

Question 39

Patients may develop tolerance to this medication necessitating a change in dosing regime A. Verapamil B. Amlodipine C. Nifedipine D. Bisoprolol E. Nicorandil F. Isosorbide mononitrate

Answer 39

Patients may develop tolerance to this medication necessitating a change in dosing regime A. Verapamil B. Amlodipine C. Nifedipine D. Bisoprolol E. Nicorandil **F. Isosorbide mononitrate**

Question 40

Why might a patient not be started on both a beta-blocker and CCB, but instead just a CCB, for the first line treament of their angina? [1] What would be the stepwise treatment if a CCB is not working? [1]

Answer 40

If the beta-blocker is contraindicated - e.g. if they have **asthma** if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: * **a long-acting nitrate** * **ivabradine** * **nicorandil** * **ranolazine**