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Cardiology > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

Ischaemic Heart disease definition

A

Myocardial ischaemia results from an imbalance between the supply of oxygen to cardiac muscle and myocardial demand. The most common cause is coronary artery atheroma (CAD). Less common causes of myocardial ischaemia are coronary artery thrombosis, spasm or rarely arterieis.

The reduction in blood flow to the heart muscle can result in:

  1. Chronic stable angina
  2. Acute coronary syndromes such as myocardial infarction
  3. chronic ischaemic heart disease
  4. sudden cardiac death
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2
Q

Definition of Angina Pectoris

A

Crushing pain or discomfort felt in the anterior chest, commonly radiating to the left arm and jaw. The pain is caused by coronary arterial insufficency leading to intermittent myocardial ischaemia

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3
Q

Pathophysiology of angina pectoris

A

Myocardial ischaemia occurs when oxygen demand exceeds supply

Supply may be reduced because:

  • stenotic atheromatous disease of epicardial coronary arteries
  • thrombosis within the arteries
  • spasms of normal coronary arteries
  • inlammation- arteritis

Demand may be increased because:

  • conditions requiring increased CO, exercise, stress
  • conditions requiring greater cardiac work - Aortic stenosis
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4
Q

Symptoms of angina

A
  • Chest pain-
    • tight, crushing, band-like pain across the centre of the chest.
    • radiaties to left arm, throat or jaw
    • precipitating factors- exercise, cold air or anxiety
    • amount of exertion required to produce angina reduces
    • relieved by rest
  • dyspnoea
  • fatigue
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5
Q

Signs of angina

A
  • breathless
  • sweaty
  • tachycardic
  • Search for underling cause: (aortic stenosis) + search for risk fators ( hypertension and xantholsama and hyperlipidaemia)
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6
Q

Diagnosis of angina

A
  • Clinical history
  • Resting ECG- May show ST segment depression and T-wave flattening
  • Excercise ECG-
    • ​positive in most people with CAD but normal test does not excude
    • Horizontal ST depression of >1mm when walking on treadmill
  • Myocardial perfusion imaging (used with excerise or pharamcological stress agents such as dobutamin) - poor perfusion of radionucleotide in ischaemic myocardium during excercise
  • Stress echo - wall motion abnormalities, decreased ejectionf raction
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7
Q

Management of angina pectoris

A

T wo fold:

  • identify and treat risk factors for CAD and offer secondary prevention
  • symptomatic treatment of angina
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8
Q

Secondary prevention in angina pectoris

A
  • Modification of risk factors
    • smoking cessation
    • control of hypertension
    • maintaining ideal body weight
    • regular excercise
    • glycaemic control in diabetes
  • Pharmacological
    • Aspirin 75mg
    • lipid lowering therapy to acheive a cholesterol level <5.0 mmol/L- statins
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9
Q

Symptomatic treatment of angina

A
  • Sublingual glycerol trinatrates tablets or spray - before exercise or during attack
  • B-adrenergic blockers - atenolol, metoprolol reduces heart rate and force of ventricular contraction to decrease myocardial oxygen demand
  • calcium antoginsts- dilitazem, amlodipine- block calcium influx, relaxing coronary arteries
  • Nitrates- reduce venous and intracardiac diastolic pressure and dilate coronary arteries
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10
Q

Surgery for angina pectoris

A

When angina persists or worsens in spite of medica therapy patient should be considered for:

  • Percutaneous intervention - consists of both percutaneous transluminal coronary angioplasty (PTCA) and intracoronary stent implantation
  • Coronary artery bypass graft (CABG)
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11
Q

Percutaenous intervention

  • Procedure
  • Advantages
  • disadvantages
A
  • Acheives revascularisation by the inflation of a small balloon across the stenotic lesion, following by a balloon dilation of the stensosis. Carried out under local anaethesia- a guidewire is passed into the aorta via the femoral or radial artery and the balloon cathere is passed over it. Once the balloon is inflated across the stenotic plawue the balloon is inflated
  • Advantages
    • patient avoid major ssurgery
    • shortened hospital stay
    • If PYCA is unsuccessful - CABG can still be performed
  • Diasadvantages
    • not all patient suited
    • instent restenosis
    • thrombosis at the site of stenting
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12
Q

Coronary artery bypass grafting

A
  • Acheives revascularisation by bypassing a stenotic lesion using grafts
  • full general anaesthsia and heart exposed via median sternotomy
  • inserting cannula into right atrium and another into proximal aorta
  • connected to bymass machine
  • Venous grafts (saphenous vein) or arterial grafts from (mammary arteris or radial arterys)
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13
Q

Definiton of Acute coronary syndromes

A

Acute coronary syndromes encompass a spectrum of unstable coronary artery disease. The common mechanism to all is rupture or erosion of the fibrous cap of a coronary artery atheromatous plaque with subsequent formation of a platelet rich clot and vasoconstruction.

Includes

  • Unstable angina
  • Non-ST elevation MI
  • ST- elevation MI
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14
Q

Diagnosis of ACS

A
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15
Q

Stable vs Unstable angina

A

Stable

  • typical cardiac pain
  • brought on by exertional and relieved by rest
  • lasting less than 20 mins

Unstable angina

  • Crescendo angina is typical angina on rapidly decreasing levels of exertion leading to
    • anginal pain at rest lasting more than 20 minutes
    • new onset angina fitting one of these two criteria
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16
Q

N-STEMI

A

Non ST elevation MI - routine heart attacks. Have worse long term outcomes than STEMI

Associated with partial coronary occlusion.

Diagnosis

  • clinical assesment, troponin measurement and ECG analysis
  • Risk factors for coronary artery disease
  • Decide whether type I vs Type II MI
17
Q

Manage unstable angina/ N STEMI

A
  • ​Morphine/Oxygen / Nitrates
  • Anti ischaemic therapy
    • beta blockers
    • nitrates
    • +/- CCB
  • Anti thrombotic
    • Aspirin and second antiplatelet (Clopidogrel)
  • Anticoagulant
    • LMWH
    • UH
    • Fondaparinx
  • Adjunct therapy
    • Statin
    • ACE Inhibitor
  • initiate medical treatment once diagnosis is confirmed (with serial troponin measurment)
18
Q

STEMI

A
  • an emergency
  • ST elevation is a sign of complete occlusion of an epicardial coronary artery by thrombus causing immediate myocardial death and relates to the territory affected
    • anterior- V1-V4
    • Inferior - II, III, AVF
    • high lateral - I, AVL
    • low lateral - V5,V6
    • posterior - dominant R wave in V1-3, with ST depression in V1-V3
19
Q

Classifciations of MI

A
  • Type 1 -spontaneous myocardial infarction -associated with ischaemia due to a primary coronary event such as thrombosis of coronary artery
  • Type 2- secondary to ischaemia due to either increased oxygen demand or decreased supply . result of ischaemi but not ischaemia from a thombus or conoary artery
  • Type 3 MI- Diagnosed post-mortem. Clearly suboptimal
  • Type 4a MI- related to percutaneous coronary intervention (ie caused by an angioplasty procedure blocking a side branch or damaging the main coronary artery causing ischaemia)
  • Type 4b MI - Related to stent thrombosis- if patient stop antiplatelets early post angiopasty or continue to smoke, stents can occlude (usually results in a STEM)
20
Q

How to Consider Conservatice vs Invasive management

A
  • Use TIMI (thrombolysis in myocardial infarction)
21
Q

Acute management of suspected ACS

A
  • Suspect ACS, do ECG, take immediate troponin and after 12 hours of onset of symptoms.
  • No evidence of beneficial effect of oxygen.
  • ACS confirmed, immediately aspirin (300 mg), clopidogrel (300 mg) (NICE suggests now ticagrelor 180mg instead or Prasugrel 10mg), LMWH or fondaparinux.
  • If no bradycardia or hypotension, and if in Killip class I considered for immediate intravenous and oral beta blockade.
  • If diabetes mellitus or marked hyperglycaemia (>11.0 mmol/l), immediate intensive blood glucose control. Continued for at least 24 hours.
  • If STEMI, immediate PCI with stent implantation. Treat with a glycoprotein IIb/IIIa receptor antagonist before PCI.
  • PCI not possible within 120 minutes of ECG diagnosis, thrombolytic therapy.
  • If fail to respond within 6 hours, rescue PCI
22
Q

Chronic management of ACS

A
  • maintain on long term aspiring 75mg
  • clopidogrel 75mg for 6 months if drug eluting stent or one month with bare metal stend
  • stop anticoaulation after 8 days
  • long term statin prior to discharge
  • maintain on long term beta blockers
  • start ACE-I within 36 hours and maintain long term
  • MI complicate by LVESD with signs of HF or diabetes should be started on eplerenone

Cardiology (12 decks)

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