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Cardiovascular Diseases > Coronary Heart Disease > Flashcards

Coronary Heart Disease Flashcards

1
Q

What is coronary heart disease and what does it encompass (in progression from least to most severe)?

A

Disease due to ischaemia of the heart

  • Angina
  • Acute Coronary Syndromes (unstable angina, NSTEMIs and STEMIs)
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2
Q

How do you differentiate between angina and an MI?

A
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3
Q

What are the two classes of angina, how do they differ?

A
  • Stable - pain precipated by specific factors, usually exercise
  • Unstable - angina at any time (considered and managed as an acute coronary syndrome)
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4
Q

What are the risk factors that can lead to angina?

A
  • Family history
  • Diabetes
  • Hypertension
  • Smoking
  • Obesity
  • Cardiac abnormalities - especially outflow obstruction e.g. aortic stenosis or hypertrophic obstructive cardiomyopathy
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5
Q

What are the three hallmarks of anginal pain? What are the categories it can be divided into based on these?

A
  1. Constricting discomfort - front of chest, neck, jaw, shoulders, arms
  2. Precipitated by physical exercise
  3. Relieved by rest or GTN in ~ 5min
  • Typical angina = All 3
  • Atypical angina = 2
  • Non-anginal chest pain = 0
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6
Q

What should be done if angina is suspected?

A
  1. Bloods looking for exacerbating factors e.g anaemia
  2. Can consider asprin if no contraindicatons and there is a high likelihood (along with other SA treatment)
  3. ECG to look for ischaemia and to exclude ACS (may be normal)
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7
Q

What are ECG signs of ischaemia / a previous MI

A
  • Pathological Q waves in particular
  • Left bundle branch block
  • ST-segment and T wave abnormalities (for example, flattening or inversion)
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8
Q

What are the diagnostic tests for stable angina and when do you use them?

A

FIRST LINE = 64-slice (or above) CT coronary angiography if:

  • Clinical assessment indicates typical or atypical angina or clinical assessment indicates non-anginal chest pain but 12-lead resting ECG has been done and indicates ST-T changes or Q waves

SECOND LINE = Non-invasive functional testing

THIRD LINE = Invasive functional testing

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9
Q

What is the treatment (excluding revascularisation) of stable angina?

A
  • Lifestyle interventions
  • Short acting nitrate for episodes - tell the patient it should resolve after 5 minutes and if does not, repeat and if does not resolve again, call an ambulance
  • FIRST LINE = ß blocker/CCB (choose based on comorbidities etc. if one doesn’t work, switch or add other)
  • CAN ADD IF FIRST LINE DOESN’T CONTROL - long-acting nitrate or ivabradine or nicorandil or ranolazine.
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10
Q

When do you consider revascularisation of a patient with stable angina and what type is chosen?

A
  • Consider when symptoms not satisfactorily controlled with optimal medical treatment
  • PCI or CABG (either, based on contraindications, then patients choice, then that PCI is cheaper)
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11
Q

How do you differentiate between the ACSs?

A
  • ST elevation ACS = STEMI
  • Non-ST elevation ACS = NSTEMI (if troponin rise), unstable angina (if no troponin rise).
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12
Q

What are the risk factors for ACSs in older and younger patients?

A
  • Classic CV risk factors
  • In younger patients think non-artherosclerotic factors
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13
Q

What are the symptoms of an ACS?

A
  • Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
  • Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
  • Chest pain associated with haemodynamic instability
  • New onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minute
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14
Q

What is the immediate management of a suspected ACS?

A
  • Start management immediately, in relation to circumstances
  • Take a resting 12 lead ECG as soon as possible, but do not delay transfer to hospital
  • Offer pain relief as soon as possible. Use GTN (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction is suspected
  • Asprin unless allergic
  • Offer antiplatelets (in hospital)
  • Further treatment is dependant on type
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15
Q

Detail the initial assessment in hospital of somone with a suspected ACS

A
  • Take a resting 12-lead ECG and a blood sample for high-sensitivity troponin I or T measurement
  • Physical exam determining haemodynamic status, signs of complications (e.g pulmonary oedema) and signs of non-coronary causes e.g. aortic dissection
  • Detailed history unless STEMI confirmed by ECG
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16
Q

Why do you test cardiac enzymes in a suspected ACS?

A

Troponin I and T are detected in serum 3-6 hours after infarction, levels peak at 12-24 hours after and remain elevated for up to 14 days) tested 6-12 hours after infarction to identify severity

17
Q

What are the impacts to an ECG of a STEMI?

A
  • >1mm ST elevation in 2 adjacent limb leads
  • >2mm ST elevation in at least 2 contiguous precordial leads
  • New onset bundle branch block
18
Q

What are the ECG signs of LBBB?

A
  • Extends the QRS duration to > 120 ms
  • Eliminates the normal septal Q waves in the lateral leads.
  • Tall R waves in the lateral leads (I, V5-6), deep S waves in the right precordial leads (V1-3), and usually leads to left axis deviation.
  • Broad or notched (‘M’-shaped) R wave in the lateral leads.
19
Q

What are the sites and corresponding leads of MI types?

A
  • INFERIOR II, III, AVF
  • ANTERIOR V1-V6
  • ANTEROSEPTAL V1-V4
  • LATERAL LEADS I, AVL
  • ANTEROLATERAL I, AVL, V1-V6
20
Q

What is the initial drug treatment of a patient with a NSTEMI/Unstable Angina?

A
  • Asprin (unless bleeding risk or hypersensitivity), clopidorgrel monotherapy is alternative
  • Antithrombin therapy - fondaparinux (unless bleeding risk or coronary angiography planned within 24 hrs of admission), unfractionated heparin if coronary angiography planned in next 24 hrs
  • Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months
21
Q

What do you do after you have given initial drug treatment for unstable angina / NSTEMI?

A
  • Assess individual risk of future adverse cardiac events using an estblished risk scoring ystem that predicts 6 month mortality e.g GRACE (global registry of acute coronary events)
  • Record relevant pMH, examination findings, ECG results, blood tests
22
Q

What are the risk groups based on the 6 month mortality percentages?

A
23
Q

What further drug treatment is offered to those at low or higher risk of future adverse cardiovascular events (those with NSEMI/UA) and what additional therapy is offered if intermediate, high or highest?

A

Those with risk >1.5%

  • Additional clopidogrel
  • Clopidogrel as a treatment option for up to 12 months
  • Discontinue clopidogrel treatment 5 days before a CABG

Those with risk >3.0%

  • IV eptifibatide or tirofiban as part of the early management if scheduled to undergo angiography within 96 hours of hospital admission
24
Q

When do you offer coronary angiography to those at low risk of adverse cardiovascular events?

A
  • Normally conservative management without early coronary angioplasty
  • Offer if ischaemia subsequently experienced or is demonstrated by ischaemia testing
25
Q

When do you offer coronary angiography to those at intermediate or higher risk of adverse cardiovascular events?

A
  • Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital
  • Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk
  • As an alternative to the combination of a heparin plus a glycoprotein inhibitor, consider bivalirudin if not already receiving a glycoprotein inhibitor or fondaparinux and will undergo PCI within 24 hrs of admission
26
Q

What is the main priority for someone with a STEMI and what are the ways of delivery?

A

Reperfusion therapy (either PCI or fibrinolysis), fibrinolysis if cannot deliver primary PCI within 120 minutes of when fibrinolysis could have been given

27
Q

What drugs and mechanical aids are offered with PCI?

A
  • Antiplatelets i.e. ticregrelor
  • Antithrombins i.e. heparin and bilvlirudin
  • Stents
28
Q

What is the method of fibrinolysis? What comes after?

A
  • Thrombolytic drugs
  • alteplase, reteplase, streptokinase or tenecteplase
  • do not use streptokinase if patient has had it previously
  • ECG 60-90 mins after, if failed to resolve PCI asap, DO NOT FIBRINOLYSE AGAIN
29
Q

What areas are identified to be controlled after a STEMI

A
  • Lipid modification and statins
  • Diabetes
  • Hypertension
  • Hyperglycaemia (post MI)
  • Cardiac rehab
  • Lifestyle advice
30
Q

What is the drug therapy post MI?

A
  • ACE inhibitors
  • dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
  • beta-blockers
  • statins
31
Q

Which coronary arteries are normally affected in inferior and anterior MIs?

A
  • Inferior = RCA
  • Anterior = LCA
32
Q

When should you not give oral ß blockers in the first 24 hours of therapy?

A

Any of the following apply

  • signs of heart failure,
  • evidence of a low output state
  • increased risk for cardiogenic shock, or
  • relative contraindications to beta blockade

Cardiovascular Diseases (9 decks)

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