Coronary Artery Disease

Question 1

What is the pathology of Coronary Artery Disease?

Answer 1

Atherosclerotic Plaques form in coronary vessels -> leads to reduced blood flow -> Myocardial ischaemia

Question 2

What are the risk factors of CAD

Answer 2

Hyperlipidaemia, Obesity, Diabetes Mellitus, Male sex, Ethnicity, Sedentary lifestyle, Hypertension, Age, SMOKING!!

Question 3

Pathophysiology of Stable Angina?

Answer 3

Atherosclerotic disease forms in the coronary arteries. Stenosis of the arteries occurs leading to myocardial ischaemia (central chest pain, alleviates with rest) brought on by exercise, cold weather, heavy meals.

Question 4

Pathophysiology of Unstable Angina?

Answer 4

Stable angina: sudden onset pain at rest and not alleviated with rest or change in typical Angina pain. Atherosclerotic plaque has ruptured leading to partial occlusion of the vessel.

Question 5

Pathophysiology of Myocardial Infarction?

Answer 5

Atherosclerotic plaque ruptures and total vessel occlusion occurs. Myocardium distal to the occlusion is ischaemic and begins to infarct.

Question 6

Clinical presentation of patient with CAD

Answer 6

Patient with central chest pain brought on by exertion, cold weather or large meals relieved by rest. Pain sometimes radiates to jaw or down left arm.
Other symptoms: Dyspnoea, sweating, clamy, palpitations, syncope, nausea and vomiting.

Question 7

Describe the investigations into Chest Pain and suspected CAD.

Answer 7

History, Examination,
ECG- look for ST changes, T-wave inversion, Old MI (pathological Q-wave)
Exercise ECG - brings on ischaemia and ECG changes
Cardioscintography - shows cardiac perfusion
CT Angiography/Angiography - identifies stenosis of vessels/atherosclerosis

Question 8

Outline the Diagnosis of Acute Myocardial Infarction.

Answer 8

History - central chest pain lasting >20minutes,
Examination - new onset murmur? Heart failure signs?

ECG - signs of ST-elevation, T-wave inversion, other ECG changes

Bloods - FBC, U+Es, TFTs,
Troponin - taken on arrival and 12hours after symptoms
CXR - Signs of Heart Failure

STEMI - ST Elevation ECG change, Chest pain and Troponin Rise

NSTEMI - Chest pain, Troponin rise, no specific ECG changes

Unstable Angina - Chest Pain, general ECG change

Question 9

Treatment Options for optimal repurfusion.

Answer 9

O2, Aspirin 300mg, Clopidagrel 300mg/Ticagrelor 180mg,

GTN sublingual spray, Morphine +/- Metaclopramide, Heparin/Dalteparin

If in 90minutes of onset –> Primary PCI

If >90minutes Thrombolysis using r-PA (teceneplase) if no contraindications

Question 10

Complications of MI?

Answer 10

Heart Failure,

Mitral Regurgitation (papillary muscle rupture/LVF)

Myocardial rupture leading to tamponade

AF

Dresslers syndrome

Sudden Death

Question 11

Management following Acute MI (Secondary medications)

Answer 11

Aspirin 75-100mg, Clopidagrel 75mg for 9-12months,

Statin

Beta blockers - help reduce demand on heart

ACEi/ARB if hypertension/signs of heart failure

Exercise rehabilitation to help improve outcomes, work rehab to ensure patient is not worried.

Risk factor reduction - smoking, weight loss, diabetes,

Question 12

Management of Stable CAD (Stable Angina)

Answer 12

risk factor reduction is main aim:

• Smoking cessation, control diabetes
• Hypertension control (Ca blockers/ACEi or diuretics)
• Statin
• Aspirin
• GTN for symptomatic relief
• Increase exercise, improve diet.