Coronary heart disease

Question 1

What are the 4 types of angina?

Answer 1

Stable - induced by effort, relived by rest
Unstable - increased frequency/severity, occurs on minimal exertion or at rest
Decubitus - precipitated by lying flat
Variant/Prinzmetal -caused by coronary artery spasm, pain at rest

Question 2

Will the troponin be raised, depleted or normal in angina?

Answer 2

Normal

Question 3

What would you expect to see on an ECG of someone with an episode of unstable angina?

Answer 3

ST depression, T-wave inversion

Question 4

What is the first line treatment for stable angina/IHD?

Answer 4

Lifestyle education PLUS aspirin 75mg OD

Question 5

What adjuncts can be added in the management of stable angina/IHD?

Answer 5

Anti-anginal therapy (e.g. beta blocker/CCB/long-acting nitrate/Ranolazine)
Statins
Antihypertensive therapy (e.g. Beta blocker/ACE-i/ARB)
Blood sugar control (e.g. lifestyle/metformin)
Revascularisation (CABG or PCI - only if persistent Sx despite max. medical therapy)

Question 6

How is an acute episode of angina managed?

Answer 6

Sublingual GTN spray. Repeat after 5 mins if symptoms not relieved. Ring 999 if symptoms not relieved 5 mins after second dose

Question 7

For patients with confirmed unstable angina (non-elevated cardiac biomarkers), what is the first line management?

Answer 7

Antiplatelet therapy consisting of daily aspirin AND clopidogrel/tacigrelor PLUS a statin PLUS cardiac rehabilitation

Question 8

What adjuncts can be used in confirmed unstable angina?

Answer 8

Beta-blocker or ACE inhibitor

Question 9

Both STEMIs and NSTEMIs produce elevated troponin levels, what differentiates them with regard to coronary artery blockage?

Answer 9

STEMI - Complete blockage of coronary artery

NSTEMI - Partial blockage of coronary artery

Question 10

What would you expect to see on ECG of a STEMI during the hyperacute and acute stage?

Answer 10

Hyperacute - tall T waves, ST elevation

Acute - T wave inversion, pathological Q waves

Question 11

After the immediate management of a STEMI (MONAC), what is the next step in management if it is less than 120 mins since the event?

Answer 11

Percutaneous Coronary Intervention (stenting the coronary artery)

Question 12

After the immediate management of a STEMI (MONAC), what is the next step in management if it is more than 120 mins since the event?

Answer 12

Fibrinolysis using streptokinase within 30 mins and transfer to the PCI centre for coronary angiography. If angiography shows it has been unsuccessful, do rescue PCI.

Question 13

After the immediate management of an NSTEMI (MONAC), what is the next step in management if the Grace score is < 3%?

Answer 13

Antithrombin therapy using Fondaparinux 2.5mg sc or unfractioned heparin if angiography planned within 24hr of admission unless planned to have PCI

Question 14

After the immediate management of an NSTEMI (MONAC), what is the next step in management if the Grace score is > 3%?

Answer 14

Offer coronary angiography within 96 hours of admission with a view to do PCI or CABG.

Question 15

What is the immediate management of acute STEMI or NSTEMI?

Answer 15

MONAC
Morphine 2.5-10mg slow iv bolus and Metaclopromide
O2
Nitrates - GTN spray
Aspirin - 300mg PO unless contraindicated
Clopidogrel - 300mg PO unless contraindicated

Question 16

What is the long term management following ACS?

Answer 16

Lifestyle modifications and B.A.S.I.C. mnemonic
B - Beta blocker
A - Aspirin
S - Statin
I - Inhibitor of ACE
C - Clopidogrel

Question 17

What scoring tool is used to identify people at risk of a cardiovascular event in the next 10 years?

Answer 17

Qrisk2 scoring tool
<10% = low risk
10-20% = moderate risk
>20% = high risk

Risk factor modification (including statins) should be considered for those with increased risk.