Cardiovascular Disease, Angina, ACS Flashcards
What happens when atheromatous plaques develop?
3 main steps
Stiffening of the artery walls - hypertension
Stenosis - reduced blood flow (e.g. in angina)
Plaque rupture - thrombus - ischaemia
Non-modifiable RF for CVD (3)
Older age
FH
Male
Modifiable RF for CVD (7)
Smoking Alcohol consumption Poor diet (high sugar and trans-fat and reduced fruit and vegetables and omega 3 consumption) Low exercise Obesity Poor sleep Stress
Co-morbidities that increase the risk of atherosclerosis (5)
Chronic Kidney Disease Hypertension Inflammatory conditions - RA Atypical Antipsychotic Medications Diabetes
Primary prevention of CVD
(Patients who have never had CVD in the past)
When to start a statin?
Perform QRISK3 (Risk of stroke or MI in next 10 years) >10% - start a statin (artorvastatin 20mg)
Which patients are routinely offered atorvastin?
CKD
T1DM >10 years or 40+
What are the NICE recommendations for checking lipids in primary prevention?
Check after 3 MONTHS
Increase statin dose to aim for a 40% REDUCTION in non-HDL cholesterol
What are the NICE recommendations for checking LFTs in primary prevention?
Check LFTs within 3 MONTHS of starting statin
Check again at 12 MONTHS
Statins can cause a transient and mild rise in ALT and AST in the first few weeks
STOP if 3X UPPER LIMIT
What is secondAry prevention of CVD?
4 As
Aspirin (plus send antiplatelet for 12 months)
Atorvastatin (80mg)
Atenolol (or other beta blocker - bisoprolol)
ACE inhibitor
Notable side effects of statins (3)
Myopathy (check creatine kinase in patients with muscle pain or weakness)
T2DM
Haemorrhagic Strokes (very rarely)
What is angina?
Narrowing of coronary arteries reduces blood flow to the myocardium
During times of high demand (exercise) there is insufficient blood flow to meet demand
Stable - relieved by rest and GTN
Unstable - Symptoms come on randomly
How do you diagnose angina?
Gold Standard - CT coronary angiography
What are the baseline investigations for someone having CT coronary angiogram?
Physical Examination (heart sounds, signs of heart failure, BMI)
FBC, U&Es (prior to ACEi and other meds), LFTs (prior to statins)
Lipid profile
Thyroid function tests
HbA1C and fasting glucose
ECG
What are the four principles of NICE management of angina?
R - refer to cardiology (urgently if unstable)
A - Advise about diagnosis, management and when to call ambulance
M - medical treatment
P - Procedures - surgical interventions
What are the aims of medical management?
Immediate Symptomatic Relief
Long Term Symptomatic Relief
Secondary prevention of cardiovascular disease
How is immediate symptomatic relief achieved?
Take GTN
Repeat after 5 minutes
If there is still pain 5 minutes after the repeat dose – call an ambulance.
How is long term symptomatic relief of angina achieved?
Beta blocker (e.g. bisoprolol 5mg once daily) or;
Calcium channel blocker (e.g. amlodipine 5mg once daily)
(both if symptoms not controlled by one)
Other options (not first line):
- Long acting nitrates (e.g. isosorbide mononitrate)
- Ivabradine (HCN chanel blocker, slow HR)
- Nicorandil (vasodilator)
- Ranolazine (late-sodium current inhibitor)
How is secondary prevention of CVD achieved?
Aspirin (i.e. 75mg once daily)
Atorvastatin 80mg once daily
ACE inhibitor
Already on a beta-blocker for symptomatic relief
What areas do the RCA supply?
Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area
What areas do the circumflex artery supply?
Left atrium
Left ventricle - Posterior aspect of
What areas do the Left Anterior Descending (LAD) artery supply?
Anterior aspect of left ventricle
Anterior aspect of septum
What to look for on an ECG for an MI?
Diagnose STEMI with:
ST elevation
New LBBB
NSTEMI - Diagnosis also needs raised troponin:
ST depression
Pathological Q waves
T wave inversion
Associated artery and ECG leads for Anterolateral area
Left Coronary Artery
I
aVL
V3-6
Associated artery and ECG leads for Anterior area
LAD
V1-V4
Associated artery and ECG leads for Lateral area
Circumflex
I
aVL
V5-V6
Associated artery and ECG leads for Inferior area
Right coronary artery
II
III
aVF
What else causes raised troponins?
CHronic renal failure Aortic dissection Myocarditis Pulmonary embolism Sepsis
Acute NSTEMI treatment
B - Beta blockers unless contraindicated A - Aspirin 300mg stat dose T - Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative) M - Morphine titrated to control pain A - Anticoagulant: LMWH N- Nitrates
What is GRACE score?
Predicts 6 month mortality or repeat MI
<5% Low risk
5-10% Medium risk
>10% High risk
Complications of MI
D - Death (VF) R - Rupture of heart septum or papillary muscles E - Edema (HF) A - Arrythmia and Aneurysm D - Dressler's Syndrome
What is Dressler’s Syndrome?
AKA Post MI syndrome
Localised immune response usually 2-3 weeks post MI
Pericarditis
Presents with:
Pleuritic chest pain
Low grade fever
Pericardial rub on auscultation
How is Dressler’s syndrome diagnosed?
ECG
- global ST elevation
- T wave inversion
Echocardiogram
- Pleural effusion
Raised inflammatory markers (CRP ESR)
How is Dressler’s syndrome managed?
NSAIDs (aspirin/ibuprofen)
Steroids in more severe cases
Secondary prevention of ACS - Medical management
6 As
Aspirin (75mg OD)
Artorvastatin (80mg OD)
ACE inhibitors
Atenolol
Aldosterone antagonist for those with CHD Another antiplatelet (clopidogrel, ticagrelor upto 12months)
Secondary prevention - Lifestyle
Stop smoking
Cardiac rehabilitation (a specific exercise regime for patients post MI)
Optimise treatment of other medical conditions (e.g. diabetes and hypertension)
Reduce alcohol consumption
Mediterranean diet
