CHD

Question 1

Pathway to STEMI or NSTEMI

Answer 1

Plaque disruption or erosion –> thrombus and embolus formation –> acute cardiac ischaemia –> elevation/nonelevation –> myocardial necrosis

Question 2

Clinical presentation of CHD

Answer 2

Central or epigastric chest pain
SOB
Nausea, vomitting, sweating, fatigue
No or little response to GTN
gradual and persistent

Question 3

Types of CHD

Answer 3

Acute coronary syndrome - a reduction in coronary artery blood flow (due to plaque disruption or erosion)

STEMI - ST elevated MI

NSTEMI/NSTEACS - non-ST elevated MI

Stable angina - chest discomfort exacerbated by exercising due to myocardial ischaemia (SOB and chest discomfort)

Question 4

CHD investigations

Answer 4

ECG - monitor ST and R wave changes
Echocardiography
Imaging of coronary arteries
Myocardial scans

Question 5

Lifestyle changes

Answer 5

weight loss! - dietary change and exercise (intensity based on exercise tolerance)

Question 6

Attack treatment - stable angina

Answer 6

1. stop and rest to correct oxygen imbalance
2. fast acting nitrate - glyceryl trinitrate (GTN)
   - AE - flushing, dizziness, HT, fainting
   - atleast 8 hour patch free period every 24 hours

Question 7

Attack prevention - stable angina

Answer 7

• BB - reduce myocardial oxygen demands
• NCCB - improve O2 supply and demand balance (verapamil, diltiazem)
• Long-acting nitrates - transdermal (GTN patches) or oral isosorbide mononitrate SR tablets or isosorbide dinitrate tablets
  - rather than slowing the heart like BB and NCCB, nitrates promote vasodilation of coronary arteries
• antiplatelets - low dose aspirin or clopidogrel
• statins - secondary prevention

ACEI - reduce preload, prevent further ventricular remodelling

Question 8

ACS treatment

Answer 8

aspirin
IV morphine - pain and vasodilation
Give GTN
Oxygen if required

Question 9

STEMI - ACS treatment

Answer 9

PCI adjuvants
- antiplatelet - low dose aspirin plus clopidogrel
- antithrombin therapy - LMWH e.g. enxoaparin

Fibrinolysis - dissolving already formed clot (clot-busting)
- fibrin selective - tenecteplase
- non-fibrin selective - streptokinase

Other
- BB
- begin antihypertensives and statins once BB use stabilised
- other drugs added based on complications e.g. spironolactone

Question 10

Post ACS treatment

Answer 10

Antiplatelets - aspirin + clopidogrel
Aldosterone antagonists - spironolactone