Chest pain TCD Flashcards
Define cardiovascular disease.
This term describes disease of the heart and blood vessels caused by the process of atherosclerosis.
What is the leading cause of death in England and Wales.
Cardiovascular disease.
What do you offer for primary prevention of CVD in those who have a 10% or greater risk of CVD.
20mg atorvastatin.
What dose of statin do you give in people with CVD?
80mg atorvastatin.
What risk assessment tool do you use to assess CVD risk?
QRISK2
What other medications can be prescribed alongside statins to lower cholesterol?
Fibrates, nicotinic acid (Niacin), ezetimibe (antihyperlipidemic, blocks cholesterol absorption in intestine)
With stable angina, why would you want to investigate anaemia?
Anaemia can exacerbate stable angina.`
Indications on an ECG of ischaemia or previous infarct include what?
- Pathological Q waves
- Left BBB
- ST-segment and T wave flattening or inversion
What do you give to patients with suspected stable angina (not yet confirmed)?
Aspirin
What is the first line investigation for typical and atypical angina, or an ECG with ST-T changes or Q waves?
64-slice CT coronary angiography.
What is the second line investigation with suspected myocardial ischaemia?
Non-invasive functional testing such as:
- MPS with SPECT (myocardial perfusion scintigraphy with single photon emission CT)
- stress echocardiography
- MRP (magnetic resonance perfusion with contrast enhancement)
What is the third line investigation if second-line non-invasive investigations are inconclusive?
Invasive coronary angiography.
What are some differential diagnoses for typical angina-like chest pain?
- Hypertrophic cardiomyopathy
- Cardiac syndrome X (angina with signs associated with decreased blood flow to heart tissue but with normal coronary arteries. sometimes referred to as microvascular angina).
What is Prinzmetal’s angina?
Also known as variant angina, is angina at rest which typically occurs in cycles. It is due to vasospasm in the coronary arteries as opposed to atherosclerosis. This may be as a result of vasospastic disorder and is associated with migraine, Raynaud’s or aspirin induced asthma.
What is the first-line treatment and prevention of angina?
Short-acting nitrates (GTN - nitroglycerin).
How do you administer short-acting nitrates>
Use it immediately before any planned exercise, spray it underneath the tongue when sat down and find something to hold onto if you’re light-headed. Repeat the dose after 5 minutes if the pain hasn’t gone and call an ambulance if the pain hasn’t gone within 5 minutes of taking the second dose.
What are potential side effects of GTN?
- flushing
- headache
- light headedness
What is the first-line treatment for stable angina?
Beta-blocker or a Ca2+ channel blocker… If one or the other doesn’t work, switch or decide on a combination. If a combination is decided, switch to a dihydropiridine Ca2+ blocker such as nifedipine, amlodipine or felodipine.
If person can’t tolerate either Ca2+ blocker or a b-blocker, what drugs can be considered for stable angina?
- long acting nitrate such as Isosorbide mononitrate
- ivabridine (funny channel blocker, cardiotonic)
- nicorandil (K+ channel opener, vasodilator)
- ranolazine (anti-angina)
What drug would you offer for the secondary prevention of CVD?
75mg aspirin for people with stable angina.
You can consider ACE inhibitors for diabetics, and statin treatment also.
What are the key features of chest pain associated with ACS?
- pain in the chest or arms/back/jaw lasting longer than 15 minutes
- chest pain associated with nausea, vomiting, sweating or breathlessness
- chest pain associated with haemodynamic instability
- new onset chest pain or abrupt deterioration occurring with little or no exertion
What is the immediate management of suspected ACS?
- Immediate 12-lead ECG
- Immediate pain relief with GTN (sublingual or buccal) and offer IV opioids such as morphine
- Single loading dose of 300mg aspirin unless allergic
- Oxygen if pulse oximetry suggests below 94% saturation or COPD below 88-92%
What are some causes of raised troponin other than ACS?
- pneumonia
- aortic dissection
- myocarditis
What is the initial drug treatment for unstable angina and NSTEMI?
- Single loading dose of 300mg aspirin.
- Antithrombin therapy of fondaparinux in patients with a lower risk of bleeding
If patients with NSTEMI or unstable angina have aspirin hypersensitivity, what else can be prescribed?
Clopidogrel monotherapy
When can you not give fondaparinux? And what would you give instead?
- patients who are to undergo coronary angiography within 24 hours of admission.
- patients who are at a high risk of bleeding.
–> Give instead: unfractionated heparin
What alternative treatment option is available for unstable angina/NSTEMI, particularly in those who are over 60, have had a previous MI or CABG, CAD etc??
Ticagrelor (anti-platelet)
What is the early management plan for those with low risk for NSTEMI/unstable angina?
300mg loading dose of clopidogrel. Offer this for up to 12 months post NSTEMI.
What is the early management plan for those with high risk for NSTEMI/unstable angina?
300mg loading dose of clopidogrel. Offer this for up to 12 months post NSTEMI.
Consider glycoprotein inhibitors such as IV eptifibatide or tirofiban.
When would you offer a coronary angiography in angina/NSTEMI cases?
You would offer this within 96 hours of first admission to medium/high risk, but not immediately to low risk. Follow up appropriately with PCI.
What are the two types of revascularisation strategy?
- PCI (percutaneous coronary intervention)
2. CABG (coronary artery bypass grafting)
What is the overall drug therapy for those who have had an acute MI?
- ACE inhibitor
- dual antiplateley therapy (aspirin + clopidogrel) and continue aspirin indefinitely and clopidogrel for up to 12 months
- b-blocker (up to 12 months)
- statin
- possible spironolactone if signs of heart failure
What are some alternative drugs used in the treatment of MI?
- ticagrelor
- rivaroxaban
- prasugrel
If b-blockers are contra-indicated in someone who has had an MI, what are some alternative drugs?
- diltiazem
- verapamil
What is nicorandil?
A K+ channel activator
What layer of the heart do the coronary arteries run through?
Epicardium
Do the coronary arteries get perfused dueing systole or diastole?
Diastole
What two physiological effects does tachycardia have on the heart?
- It increases oxygen demand
2. It reduces coronary blood flow
What major vessel is responsible for venous drainage from the heart?
The coronary sinus
