CVD - Ischaemic heart disease Flashcards
What (8) are the key cardiac risk factors?
- Increasing age
- Family history of IHD
- Obesity
- Sedentary lifestyle
- Smoking history
- Hypercholesterolaemia
- Hypertension
- Diabetes
What (5) are the presenting symptoms of IHD?
- Ischemic chest pain
- Shortness of breath
- Palpitations
- Syncope
- Lethargy
Compare the ischaemic chest pain
- stable angina
- unstable angina
- MI
Stable Angina
•Pain comes on with exercise, cold, stress
•Relieved by rest
•No recent change
Unstable Angina
•New onset pain or pain at rest
•Pain at lower levels of exercise
Myocardial Infarction
•Pain at rest
What is the definition of an acute myocardial infarction? i.e. how do you diagnose it?
The WHO definition of an AMI requires at least 2 of the following 3 features
- Symptoms of myocardial ischaemia
- Elevation of cardiac markers (troponin or CK)
- Typical electrocardiographic pattern involving the development of Q waves, ST segment changes or T wave changes
What is an acute coronary syndrome?
An acute coronary syndrome is usually caused by coronary thrombosis, in association with a ruptured atherosclerotic plaque.
This causes acute narrowing or occlusion of coronary artery (pain due to acute reduction in myocardial O2 supply)
Clinically this presents as either:
1) ST elevation MI
2) Non ST elevation MI
3) Unstable angina
4) Sudden cardiac death
What timeline of reperfusion is optimal for ACS?
Less than 4 hours
What is the preferred reperfusion strategy?
Primary Percutaneous Intervention (PCI) is generally preferred to Fibrinolysis
Primary PCI preferred
• Skilled lab
• Door to balloon time
What are adjunctive therapies in acute MI?
- Oxygen
- IV morphine
- Aspirin
- IV heparin or s/c clexane
- IV GTN
- Additional antiplatelet agents if stent inserted (clopidogrel, prasugrel, ticagrelor)
What is the evidence for beta blockers & angiotension coverting enzyme (ACE) inhibitors after an AMI?
- Beta Blockers administered following an acute MI REDUCE morbidity & mortality (up to 15%) as shown in multiple trials. Effects include reducing rates of recurrent MI, reducing angina, reducing arrthymias & improving LV function
- Many randomized trials have demonstrated that ACE inhibitor therapy started within 24 hours to 16 days following an acute MI IMPROVES the left ventricular ejection fraction & reduces mortality
What (4) are the XR features of LVH?
Cardiomegaly
‘bats wing’ appearance
Kerley B lines
Pulmonary oedema
(5) Complications of acute myocardial infarction by the pathology
- Ischaemic: angina, reinfarction, infarct extension
- Mechanical: Heart failure, cardiogenic shock, mitral valve dysfunction, aneurysms, cardiac rupture
- Arrhythmic: Atrial or ventricular arrhythmias, sinus or atrioventricular node dysfunction
- Embolic: Central nervous system or peripheral embolization
- Inflammatory: Pericarditis
How do we treat complications of acute myocardial infarction? (think of the 5 pathological classes)
- ischaemic
- mechanical
- arrhythmic
- embolic
- inflammatory
- Ischaemic: Revascularisation (PCI or CABGS)
- Mechanical: Consider surgical intervention
- Arrhythmic: Antiarrhythmics, pacemaker or implantable defibrillator
- Embolic: Consider anticoagulants or antiplatelet agents
- Inflammatory: Anti-inflammatory agents
What are the post-hospital management of an AMI?
- modify lifestyle
- Modify cardiac risk factors:
•Diabetes: management plan (BSL & HBA1C targets, diabetic educator, dietician etc)
•Hypercholesteroleamia: aim total chol less than 4.0 mmol/l & LDL less than 1.8 mmol/l for secondary prevention
•Hypertension: salt restriction & weight reduction - Medications
What is the target total cholesterol & LDL level in secondary prevention of AMI?
Total cholesterol: less than 4.0mM
LDL: less than 1.8mM
What is the typical Post-hospital management of Acute ST elevation MI?
- Review at 1 month then 6 monthly thereafter
- Repeat echocardiogram at 6 months
- Stress testing (nuclear exercise or stress echo) at 1 year
- Cholesterol profile, renal, liver function, CK, FBE etc 6 monthly
- Regular review of lifestyle changes
- Regular review of medication chart & compliance
