Coronary Heart Disease

Question 1

What are some of the conditions that occur in those with coronary heart disease?

Answer 1

Angina (Stable or unstable)
NSTEMI - Non-ST Elevated Myocardial Infarction (Type I and II)
STEMI - ST Elevated Myocardial Infarction

Question 2

How can Coronary Heart Disease lead to cardiac arrest?

Answer 2

Occlusion of the coronary arteries can cause ischaemia and acute myocardial infarction
This leads to fibrosis of the myocardium, making it electrically unstable, leading to ischaemic cardiomyopathy
With some modifiers such as ischaemic burden, autonomic variation, some drugs and genetics, this can lead to cardiac arrest

Question 3

What is meant by VSD?

Answer 3

Ventricular Septal Defect (Hole in the ventricular septum)

Question 4

What is meant by a Type I Myocardial Infarction?

Answer 4

Ischaemia of the myocardium due to partial (NSTEMI) or complete (STEMI) occlusion of the coronary arteries by an atheromatous plaque and thrombus

Question 5

What is meant by a Type II Myocardial infarction?

Answer 5

Ischaemia of the myocardium caused by another disease that increases the oxygen demand to the heart, while oxygen supply is not increased (Not caused by atheroma formation)

Question 6

How is a type II myocardial infarction diagnosed?

Answer 6

Symptoms of MI
Abnormal ECG (STEMI)
Troponin in the blood due to cardiac injury

Question 7

What is the common SOCRATES description for stable angina?

Answer 7

S - Site - Chest (Hard to localise)
O - Onset - During exercise or physical activity
C - Character - Squeezing, heaviness
R - Radiating - To arm, back, neck, jaw
A - Assoc symptoms - X
T - Timing - Usually patterns of timing
E - Exacerbating - Exertion, stress, cold (Reliefed by rest or GTN spray)
S - Severity - X

Question 8

What are some Differential diagnoses of chest pain relating to the GI tract and their characteristics?

Answer 8

Reflux - Burning, water brash, food provoked
Peptic ulcer - Epigastric, boring, relief by antacids
Oesophageal spasm
Biliary colic (Gallstone trapped in duct)

Question 9

What are some differential diagnoses of chest pain relating to the musculoskeletal system and their characteristics?

Answer 9

Injury - Exact location, prolonged, exacerbated by movement
Nerve root pain

Question 10

What are some differential diagnoses of chest pain relating to the pleura and pericardium and their characteristics?

Answer 10

Pericarditis - Central, posture related
Pleurisy - Focal, exacerbated by breathing, sharp, catching pain

Question 11

What are some emergency differential diagnoses of chest pain and their characteristics?

Answer 11

Myocardial infarction - Severe, associated autonomic upset, agor amini, ongoing pain despite >10mg morphine
Pulmonary embolism - Breathlessness, dull, pleuritic pain
Aortic dissection - tearing, excruciating, severe and then eases as dissection stops

Question 12

What is agor amini?

Answer 12

The impending sense of death or doom, commonly associated with a myocardial infarction

Question 13

What are some common scans to test for Coronary Heart Disease?

Answer 13

Exercise Stress Testing
Perfusion Scanning
CT Angiography
Angiography

Question 14

What are the advantages of exercise testing?

Answer 14

It is cheap, reproducible and a positive test at a low workload can show a poor prognosis (Determines severity)

Question 15

What are the disadvantages of exercise testing?

Answer 15

It has a poor diagnostic accuracy in certain, important groups (e.g. elderly may not be able to do exercise because of age)

Question 16

What happens in perfusion scanning?

Answer 16

A radioactive tracer is given which is taken up by the heart tissue
Stress due to exercise or medication will show gaps in tissue uptake due to ischaemia

Question 17

What are the advantages of perfusion scanning?

Answer 17

It is non-invasive
It is much more precise than exercise testing
It allows for risk stratification, to determine the correct level of care

Question 18

What are the disadvantages of perfusion scanning?

Answer 18

It involves radiation
It can give false positives and negatives

Question 19

What are the advantages of CT angiography?

Answer 19

It is non-invasive
It can provide anatomical data and risk stratification to determine the correct level of care

Question 20

What are the disadvantages of CT angiography?

Answer 20

It involves radiation from CT scanning
It is less precise than normal angiography, especially in calcified heart walls
It is expensive

Question 21

What occurs during angiography?

Answer 21

A sheath is inserted into either the radial or femoral artery and is passed into the coronary ostium (Opening to coronary arteries)
This then injects an X-ray contrast agent into the arteries so that is can be imaged

Question 22

What are the advantages of angiography?

Answer 22

It is gold standard
It provides anatomical and risk stratification

Question 23

What are the disadvantages of angiography?

Answer 23

There is a 1/1000 risk of death and stroke
It involves radiation from the X-ray
Contrast can cause renal dysfunction, rash and nausea