Cardiovascular Flashcards
Pathophysiology of IHD
- primarily caused by atherosclerosis
- when 70-80% sclerosed → exertional symptoms → angina
What is the mechanism of atherosclerotic plaque formation?
- fatty streaks
- intermediate lesions
- fibrous plaques of advanced lesions
- plaque rupture → infarction
What is an atherosclerotic plaque?
complex lesion consisting of:
- lipid
- necrotic core
- connective tissue
- fibrous cap
What are the major cell types involved in atherogenesis?
- endothelium
- macrophages
- smooth muscle cells
- platelets
What arteries does atherogenesis affect most commonly?
- LAD
- circumflex
- RCA
Risk factors of IHD
- family history
- age
- South Asian
- smoking
- poor nutrition
- sedentary lifestyle
- alcohol
- stress
- HTN
- obesity
- DM
Presentation of angina
- constricting discomfort in front of chest, neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest/GTN spray (5 mins)
normal exam
- typical angina = all 3
- atypical angina = 2
- non anginal pain = 1/none
Investigations for IHD
- ECG usually normal
- lipid profile → high LDL
- FBC
- HbA1c
GOLD STANDARD = CT coronary angiography
Treatment of IHD
- antiplatelet therapy → aspirin/clopidogrel
- lipid lowering thearpy → statin
- good hypertensive/glycaemic control
Treatment for angina
- symptomatic relief = GTN spray
- long term symptomatic relief = beta blocker/CCB
- secondary prevention = AAA
- PCI/CABG if extensive damage
What is the secondary prevention for angina?
AAA
- aspirin
- atorvastatin
- ACEi
What surgical interventions are available for angina?
- percutaneous coronary intervention
- coronary artery bypass graft → preferred in patients with diabetes, >65
What is ACS?
Acute Coronary Syndrome
- thrombus from an atherosclerotic plaque blocking a coronary artery
- unstable angina = ischaemia
- STEMI = complete occlusion
- NSTEMI = partial occlusion → subendocardial infarction
Presentation of ACS
- central constricting chest pain radiating to jaw/arms
- sweating
- SOB
- >20 mins
- unstable angina → pain not relieved by rest or GTN spray
- silent MI → in diabetics
ECG changes in ACS
STEMI
- ST segment elevation
NSTEMI/unstable angina
- ST depression
- deep T wave inversion
How do you differentiate between unstable angina and NSTEMI?
- unstable angina = troponin normal
- NSTEMI = troponin abnormal
Immediate management of ACS
MONAC
- morphine
- oxygen
- nitrate
- aspirin
- clopidogrel
Management of STEMI
PCI within 120mins
- clopidogrel/prasugrel and aspirin
Fibrinolysis if not PCI eg alteplase
- ticagrelor and aspirin
Management of NSTEMI/unstable angina
- GRACE score
- fondaparinux
low risk
- ticagrelor
- aspirin
medium/high risk
- angiography and PCI
- prasugrel and aspirin
What is the GRACE score?
- assess for PCI in NSTEMI
- gives 6 month risk of death and repeat MI after having a NSTEMI
Secondary prevention of ACS
ACAB
- ACEi
- clopidogrel
- aspirin and atorvastatin
- beta blocker
What are the post MI complications
DREAD
- death
- rupture of heart septum/papillary muscles
- edema (HF)
- arrhythmias and aneurysms
- Dressler’s syndrome
Definition of HTN
- >140/90 in clinic (be aware of white coat HTN)
- >135/85 with ABPM/home readings
Pathophysiology of HTN
95% idiopathic = essential HTN
rest = underlying cause → ROPE
- renal disease
- obesity
- pregnancy (pre-eclampsia)
- endocrine (Conns)
