Coronary Heart Disease and Revascularisation

Question 1

What coronary artery disease is considered stable, and which are considered unstable?

Answer 1

Angina = stable

NSTEMI/STEMI = unstable

Question 2

Coronary artery disease can cause cardiogenic shock. What does this mean?

Answer 2

• Inadequate systemic perfusion as a result of cardiac dysfunction

Question 3

Describe the normal clinical presentation of angina pain

Answer 3

• Pressing, squeezing, heaviness, a weight,
• Radiating to arm(s), back, neck, jaw, teeth
• Brought on by exertion, stress, cold wind, after meals
• Present for a few minutes, relieved by rest OR GTN

Question 4

What are the potential differential diagnoses for central chest pain?

Answer 4

- GI tract origin
=> Reflux
=> peptic ulcer pain 
=> Oesophageal spasm 
=> Biliary colic 

• MSK origin
  =>  Injury (exacerbated by moving particular area)
  => nerve root pain
• Pericarditis
• Pleuritic pain
  e. g. PE => exacerbated by breathing

Question 5

What conditions presenting with chest pain are considered an emergency?

Answer 5

Myocardial infarction

• Severe pain
• associated autonomic upset (sweating etc)
• Ongoing pain, despite >10mg Morphine

Pulmonary embolus
- associated breathlessness

Dissection of aorta
- excruciating, severe then eases

Question 6

How can patients be investigated for stable angina?

Answer 6

Exercise testing
- aims to reproduce symptoms they experience on exertion but not at rest

Perfusion testing
- non invasive but does require radiation dose

CT angiography
- non-invasive but radiation required

Question 7

Describe how angiography is carried out?

Answer 7

• Sheath inserted into artery
• Catheter advanced from wrist / groin to coronary arteries
•   X-ray contrast agent injected to outline coronaries and any occlusions

Question 8

Which test should be used for angina investigation depending on the patient’s age?

Answer 8

Older patient typical symptoms

• Exercise test for risk
• angiography for management

Younger patient, atypical symptoms
- don’t do exercise test as there is a high false positive rate

Question 9

What drugs are used to relieve symptoms of angina?

Answer 9

Aspirin => Antiplatelet
ß blockers => Slow heart rate, reduce O2 demand
Statin => Reduces cholesterol
ACE inhibitor =>  Reduces blood pressure

Question 10

WHat lifestyle measures are recommended to patients with angina to help treat their condition

Answer 10

 Stop smoking
 Take exercise
Eat a good diet

Question 11

What vessels can be used to perform a CABG procedure?

Answer 11

• Long saphenous vein
• Internal Mammary artery (comes off aorta)
• radial artery

Question 12

What are the potential complications of a CABG procedure?

Answer 12

Death
Stroke
MI
Atrial fibrillation 
Infection 
Cognitive impairment
Sternal malunion 
Renal failure

Question 13

What are the potential complications of PCI?

Answer 13

Death
Stroke
MI
Renal failure 
Bleeding 
Vascular complications

Question 14

Describe a PCI procedure

Answer 14

• Vascular access
• Anti-platelets and anticoagulation
• Catheter to coronary arteries
• Guidewire down vessel
• Balloons threaded over wire
• Stent(s) implanted

Question 15

PCI needs to be completed within how many minutes of a patient arriving to the hospital?

Answer 15

30 mins

Question 16

If PCI is not suitable due to the time frame, what intervention can be used in an attempt to dissolve the clot?

Answer 16

Thrombolysis

- streptokinase

Question 17

What is the revascularisation approach for STEMI vs NSTEMI vs Stable Angina?

Answer 17

STEMI
- Primary PCI

NSTEMI/ Acute coronary syndrome
- angiography with a view to revascularisation

Stable angina

• Revascularisation for severe symptoms or high risk
•   CABG vs PCI should be determined by discussion