Coronary heart disease (3.5)

Question 1

What are the non-modifiable risk factors for coronary heart disease? (4)

Answer 1

Age (>35)
Ethnicity (Black, Southeast Asian, Hispanic)
Gender (male)
Family history (first degree relative <65y)

Question 2

What ECG changes could be present in coronary heart disease? (5)

Answer 2

1. ST segment elevation
2. ST segment depression
3. T wave abnormalities. Hyperacute T- waves are usually the first indication of an acute MI. T wave inversion can indicate ischaemia.
4. Pathological Q waves usually indicate current or prior myocardial infarction. Q waves are considered pathological if:
   a. > 40 ms (1 mm) wide
   b. > 2 mm deep
   c. > 25% of depth of QRS complex
   e. Seen in leads V1-3
5. Left bundle branch block (LBBB). ECG characteristics of LBBB are:
   a. Broad QRS (>3 small square/0.12sec) and
   b. Deep S wave in V1 and
   c. No Q wave in V5/V6

Question 3

What are the modifiable risk factors for coronary artery disease? (7)

Answer 3

Hypertension
Hyperlipidaemia (high LDL, low HDL)
Exercise
Smoking
Obesity
Diabetes mellitus
Inflammatory disease (Rheumatoid arthritis, lupus erythematosus, IBS)

Question 4

What are the NICE diagnostic criteria for anginal chest pain? (3)

Answer 4

Constricting discomfort in front of chest, neck, shoulders, arms
Precipitated by physical exertion
Relieved by GTN or rest in about 5 minutes

Question 5

Define stable angina

Answer 5

Atherosclerosis and atheroma formation narrows coronary arteries. During exercise, the myocardial demand for oxygen is not met, resulting in anginal chest pain.

Question 6

Define ACS

Answer 6

Acute Coronary Syndrome
STEMI, NSTEMI, Unstable angine
The rupture of a plaque can result in platelet aggregation, thrombus formation and occlusion of an artery

Question 7

What is the difference between a STEMI and an NSTEMI/unstable angina?

Answer 7

STEMI= total and persistent occlusion
NSTEMI/unstable angina= Partial or temporary occlusion

Question 8

What investigation should be performed immediately on patients with at least 15 minutes of chest pain? Why?

Answer 8

12 lead ECG
Exclude ST elevation

Question 9

What blood test should be investigated on a patient with chest pain but no ST elevation?

Answer 9

Troponin

Question 10

What is the normal range of Troponin-I?

Answer 10

0-14ng/L

Question 11

What’s the gold standard diagnosis of an acute MI?

Answer 11

50% rise or fall in Troponin within 3-6 hours after onset of chest pain.
Elevated troponins after 6 hours

Question 12

What is a GRACE/HEART score?

Answer 12

Risk stratification calculator for patients with ACS
(Global Registry of Acute Coronary Syndrome)
(History, ECG, Age, Risk factors, Troponin)

Question 13

What tests can GPs perform to establish risk of CHD?

Answer 13

Pulse
Saturations
Blood pressure
Cardiovascular and respiratory examination
Weight and height and calculates his BMI
Urine dipstick to look for glucose
Baseline blood tests to assess risk factors including renal function, HbA1C for diabetes and a lipid profile
Ambulatory blood pressure monitor

Question 14

What is a QRISK3 score?

Answer 14

A GP tool for 10 year risk of cardiovascular events.

Required:
Age
Gender
Smoking status
History of diabetes, hypertension
Family history of cardiovascular event
Physical exercise
Diet
BMI
Cholesterol

Additional:
Chronic kidney disease, which now includes stage 3 CKD
Migraine
Corticosteroids
Systemic lupus erythematosus (SLE)
Atypical antipsychotics
Severe mental illness
Erectile dysfunction
A measure of systolic blood pressure variability

Question 15

What should be prescribed to all patients with CHD as a primary prophylaxis?

Answer 15

Aspirin 75mg OD

Question 16

What advise should be given to patients with angina if they experience another episode of heart pain?

Answer 16

Stop what they are doing and rest.
Use GTN spray as instructed (single puff once seated).
Take a second dose of GTN after five minutes if the pain has not eased.
Call 999 for an ambulance if the pain persists for 15 minutes despite the use of sublingual GTN, or earlier if the pain is intensifying or you feel unwell (associated clamminess, nausea, dizziness).

Question 17

Why is it important to document if a patient is experiencing chest pain whilst undergoing an ECG?

Answer 17

After chest pain has subsided, NSTEMIs and unstable angina often have a normal looking ECG

Question 18

What is the mnemonic used for treatment of acute ACS patients in hospital?

Answer 18

MONAC

Question 19

What does MONAC stand for?

Answer 19

Treatment plan for patients with ACS

Morphine
Oxygen (if hypoxic <94%)
Nitrates
Aspirin
Clopidogrel

Question 20

What parameters need further monitoring for patients with ACS whilst awaiting blood results for troponins?

Answer 20

Pulse and blood pressure
Heart rhythm
Checking pain relief is effective
Repeated resting 12-lead ECGs
Exacerbations of pain and/or other symptoms
Oxygen saturation by pulse oximetry

Question 21

What are the NICE guidelines for acute STEMI?

Answer 21

Primary PCI
Dual antiplatelet. Aspirin + Prasgrel (not already takin an oral anticoag), or Clopidogrel (already taking an oral anticoag, risk of bleeding)