Condition- Ischaemic Heart Disease Flashcards
Define what angina pectoris is…
Chest pain or discomfort due to myocardial ischaemia which is brought on by exertion and relieved by rest.
Briefly describe the pathophysioloy behind angina
- Atheromatous plaque leads to stable obstruction of coronary artery
- Imbalance between myocardial oxygen supply and demand
List some of the risk factors for developing IHD
- smoking
- hypertension
- hyperlipidaemia
- isolated low HDL cholesterol
- diabetes
- inactivity
- obesity
- family history of premature coronary heart disease
- male sex
- illicit drug use
Describe the different classifications of Angina
- STABLE: indued on exertion, relieved by rest
- UNSTABLE: worsening + increasing frequency. Minimal exertion
- DECUBITUS: on lying down. Pooling of blood in legs when stading –> lying –> increased preload and myocardial work (HF complication)
- PRINZMETAL: Due to Coronary artery spasms often noticed at night. . The angina is associated with transient ST elevation (bunny ears) during attacks and negative stress ECG.
Describe the presentation of patients with angina
TYPICAL SYMPTOMS:
- Central chest tightness lasting several minutes
- Provoked by exercise or stress
- Relieved with rest or glyceryl trinitrate
ATYPICAL SYMPTOMS:
- May radiate to one or both arms, neck, jaw or teeth
- Associated symptoms: dyspnoea, nausea, sweatiness, faintness
List some of the signs on physial examination of a patient with angina
- USUALLY NORMAL
- might see tachycardia- this could bring on an angina episode
Which investigations could you perform on a patient with Angina?
- Resting ECG- usually normal, may see some ST depression indicative of ischaemic changes
- FBC- anaemia exacerbates angina
- Fasting Lipid Profile: elevated LDL is a risk
- HbA1c: hypergylcaemia is a part of the metabolic syndrome associated with IHD
How would you manage a patient with stable angina?
- Lifestyle advice: reduce risk of future cardiovascular events- weight management, increased physical activity, dietary modifications, lipid goals, and smoking cessation
- Antiplatelet therapy
- Anti-anginal therapy:
- Beta Blockers
- CCBs e.g. amlodopine
- Nitrates- GTN
- Metabolic Syndrome Management:
- Statins
- BG management
- Hypertensive control
List some of the contra- indications for pescribing Beta Blocker…
- Asthma
- Bradycardia, AV Block
- PVD
- Depressio
List some of the side-effects of Beta Blockers
- Fatigue
- Lethargy
- Restlessness
- Impotence in men
What is Ischaemic Heart Disease?
Characterised by decreased blood supply to the heart muscle resulting in chest pain (angina pectoris). May present as stable angina or acute coronary syndrome
Descirbe what Acute Coronary Syndrome is and what it can be subdivided into?
A spectrum of acute myocardial ischaemia and/or infarction subdivided into:
- UNSTABLE ANGINA: chest pain at rest due to ischaemia but without cardiac ijury
- NSTEMI: severly occluded coronary artery but not completely blocked
- STEMI: ST elevation with transmural infarction
List the causes of Angina Pectoris
A VASE
- Atheroschlerosis
- Vasculitis
- Arteritis
- Spasms
- Emboli
List some of the presenting symptoms of ACS
Chest Pain:
- S: central chest pain
- O: Acute onset during rest
- C: heavy, tight, crushing
- R: radiates to arms, neck, jaw or epigastrium
- A: SOB, sweating, palpitations, nausea and vomitting, syncope
- T: worse than stable angina + increasing frequency. Episodes >20mins
- E: Relieved by GTN but not rest
List some of the signs you may see on physical examination of someone with ACS…
- May be NO CLINICAL SIGNS
- INSPECTION: Pale, Sweating, restless, distress
- PALPATION: high/ low pulse may be poor, arryhtmias, BP disturbance
- AUSCULATION: New S4 sound, carotid bruits, murmur, rales (if LV failure)
- Signs of complications (e.g. acute heart failure, cardiogenic shock)
- Signs of heart failure are increased JVP, 3rd heart sound, basal crepitations
Which Investigations could be ordered for someone with suspected ACS?
- Bloods
- ECG
- CXR- check for signs of HF, cardiomegaly or pulmonary oedema
- Stress ECG: for troponin-negative ACS or stable angina with a high pretest probability of coronary heart disease
- Echo- rest and stress. May see transient regional wall motion abnormalities and can determine if defect is reversible (ischaemic) or fixed (scarring)
- Coronary Angiography: see coronary artery stenosis
Which bloods could you order?
- FBC: anaemia is risk
- U&Es:
- Lipid profile: high LDL is risk
- HbA1c: diabetes is risk
- TFTs: Thyrotoxicosis is risk
- Cardiac Enzymes: elevated troponin and CK-MB observed in NSTEMI + STEMI but not UA
Describe what you would see in the ECG of someone with an ACS?
- UA: ST depression, T inversion or normal
- NSTEMI: ST depression + T inversion, transient ST elevation or normal
- STEMI: ST elevation >20mins, in >/= 2 leads
Describe the relationship between the ECG leads and the side of the heart?
- Inferior: II, III, aVF (supplied by right coronary artery)
- Anterior: V1-V5/6 (left anterior descending artery)
- Lateral: I, aVL, V5/6 (left circumflex artery)
- Posterior: Tall R wave and ST depression in V1-3
How would you manage a patient with Unstable Angina/ NSTEMI?
MONABASH
- Morphine
- Oxygen
- Nitrates (GTN)
- Antiplatelets- aspirin or clopidogrel
- Beta-blockers/ CCBs
- ACE inhibs
- Statns
- Heparin
How would you manage a patient with a STEMI?
- EMERGENCY REVASCULARISATION:
- PCI
- CABG if PCI fails
- MONABASH therapy
- Thrombolysis: Altepase (tPA)
List some contra-indications for prescribing thormbolytics…
- prior intracranial haemorrhage
- malignant intracranial lesion or structural cerebral vascular lesion (e.g., arteriovenous malformations)
- ischaemic stroke within previous 3 months
- suspected aortic dissection
- active bleeding or bleeding diathesis
- significant closed head or facial trauma within previous 3 months
Basically anything with increased risk of bleeding and haemorrhage
List some of the common complications of ACS
- MI
- Stroke
- PVD
- Heart Block
- Pericarditis
- Heart Failure
- Ventricular Aneurysms
- Arrhythmias
List some of the common complications of an MI
DARTH VADER
- Death
- Arrhythmias
- Rupture – of septum or outer walls
- Tamponade
- Heart failure
- Valve disease
- Aneurysm
- Dressler’s syndrome – autoimmune pericarditis 2-10 weeks after MI due to molecular mimicry
- Embolism
- Reinfarction
How can you monitor the risk of further bleeding in someone with MI?
Thrombolysis in Myocardial Infarction (TIMI)
High scores are associated with high risk of cardiac events within 30 days of MI
