Coronary heart disease Flashcards
What causes sudden cardiac death?
Stable plaque => unstable plaque => transient ischemia => cardiac arrest
Acute occulsion => acute MI => Cardiac arrest
Chronic closure => scarr formation => Cardiac arrect
Ischemic cardiomyopathy => cardiac arrect
How is anginal diagnosed?
A good clinical history
What do you need to ask about in an angina history?
Visceral pain from myocardial hypoxia- difficult to describe (gestures) pressig squeezing heavines, weight radiating to back, jaw, arms and teeth
Characteristic patterns of:
Provocation (exercise , stress, large meal, cold wind
Relief - rest GTN spray
Timing- usually lasts 1-2 minutes
What are the differential diagnosis of chest pain?
GI tract = oesophageal reflux, peptic ulcer pain, oesophageal spasm (relieved by GTN), billary cholic
MSK = injury or nerve root pain (dermatomal and prolonged)
CVS = Pericarditis- central and relieved by a change in posture which stops pericardial rubbing
Resp = Pleuritic chest pain- focal and exacerbated by breathing
WHat are the common presentations of MI?
Severe chest pain, associated sweating, neusea and vommiting, fear, adrenaline, sense of impending doom. Ongoing despite 10mg morphine
What is the presentation of PE?
Breathless, dull pain, pleuritic is a peripheral artery is affected
What is the presentation of aortic dissection?
Tearing, excruciating pain which eases. INcreased BP and massive ordeal
Angina is a clinical diagnosis but how is the presence of CHD confirmed?
Tests and investigations
Is it possible to have CHD without angina and angina without CHD?
Yes
What are the advantages and disadvantages of exercise testing?
+ Cheap, reproducible, Risk stratification (a positive test at low work load implies a poor prognosis, and a negative test at high workload implies a good prognosis)
- Poor diagnostic accuracy in women (false positives), submaxiaml tests (existing lung disease/arthritis may limit workload prematurely
When is exercise tolerance testing done occupationally?
For HGV drivers and pilots for fitness to work
What are the advantages and disadvantages for perfusion scanning?
+ non invasive, pharmacological stress in ledd mobile patients, more pricise than ETT, risk stratification
- Radiation and flase positives/negatives
What are the advantages and disadvantages of CT angiography?
+ NOn invasive, anatomical data, risk stratification
- Radiation (less than perfusion scanning), expensive, less precise than perfusion if Ca++ present
What are the advantages and disadvantages of catheter angiography?
+ gold standard, anatomical data, risk stratification and follow on angioplasty
- Risk 1 in 1000 death/stroke, radiation, contrast can cause renal dysfunction, rash, nausea
What is a catheter angiography?
A sheath inserted into radial/femoral artery and catheter advanced to coronary ostium. X ray contrast injected to outline coronary arteries and video fluoscopy images recorded in multiple views
What are the 3 main factors to CHD management?
Drug therapy
Lifestyle modification
Revascularisation
Which drugs are commonly used in CHD?
Antiplatelets- asprin
Beta blockers to reduceheart rate and oxygen demand
Statin to reduce cholesterol
ACE inhibitor/ARB to reduce BP
What is a CABG?
Coronary artery bypass graft
The diversion of blood around narrow or clotted parts of coronary arteries to improve perfusion
What is the euroSCORE?
European system for cardiac operative risk evaulation
What is the surgical technique for CABG?
1) Median sternotomoy
2) Use long saphenous vein or internal mamory artey
3) Put on cardiopulmonary bipass to stop the heart
4) Cardioplegia- heart is kept alive in a cold solution with salts inc K+ to stop the heart
5) Overnight in ITU, 7 days in hospital and 2-3 months off work
6) Risk of graft disease 8-10 years post opp (vein grafts are not designed for arterial pressure
What are the complications of CABG?
1-2% mortality, 2-3% stroke, 3% MI AF Sternal maluniion Infection Renal failure Cognitive impairment Failure to recover- hard to be confident about life
What is primary PCI?
Percutaneous coronary intervention
Performed by interventioal cardiologists i the cath lab
How is PCI carried out?
1) Vascular access (radial or femoral artery)
2) Antiplatelet and anticoagulation therapy
3) Catheter to ostia of coronary arteries
4) Guidewire down vessel, ballons threaded over wire and stents implanted
5) Balloon catheter and wires removed
What are the complications of primary PCI?
0.8%death, 0.6% stroke, 1-2% MI Renal failure Bleedig Vascular complications Stent thrombosis Stent restenosis Emergency CABG if you cannot sort the problem
