drugs for ischaemic heart disease

Question 1

drugs known to improve prognosis of angina

Answer 1

aspirin
clopidogrel
statins

Question 2

comparison of percutaneous transarterial coronary arteriography vs alteplase fibrinolysis

Answer 2

N=1572 with MI PTCA or alteplase
No difference in immediate mortality
PTCA better for preventing recurrence
fibrinolysis-higher bleed rate

Question 3

the most important thing to remember in acute MI patients

Answer 3

that the speed of diagnosis and treatment has a significant effect on mortality. a door to needle time of under 30 mins has an in hospital mortality of 2%. over 45mins has a mortality of 7%.

Question 4

Treatment of MI (London)

Answer 4

1 - Ambulance
Diagnosis
Aspirin

2 - Hospital
Primary angioplasty
Stent
Clopidogrel (depending on stent)

Question 5

Acute chest pain at rest decision flow chart

Answer 5

proven to reduce mortality

1 - Typical history, ST elevation?

if yes then diagnosis MI - Defib available
Oxygen
Diamorphine/metaclopramide
Aspirin 300mg #
PTCA #
b-blocker # 
ACE inhibitor #
Statin #
Nitrate for pain
(clopidogrel-probably not)

if no then:
2 - Hx, ECG and trop T?

if yes then NSTEMI/ UA (unstable angina) -
Defib available
Aspirin 300mg #
b-blocker
Nitrate infusion for pain 
LMW heparin (or UF) #
Statin #
GpIIb/IIIa receptor blocker if high-risk #
?coronary angiogram/PTCA

if no then not coronary pain

Question 6

what is ACS

Answer 6

acute coronary syndrome - contains acute MI, NSTEMI and unstable angina.

NSTEMI is diagnosed with a raised trop T where as Unstable angina is a clinical diagnosis.

Approximately 12% of patients admitted to hospital with unstable angina/NSTEMI suffer MI within 2 weeks

Question 7

use of angiography in stable angina

Answer 7

gold standard
disease patterns influence prognosis
eg LMS, 3VD, 2VD/LMS may benefit from revascularisation BUT morbidity 1/1000, mortality 1/10 000 RELATED TO PROCEDURE NOT DISEASE

Therefore patients are stratified prior to angiography with non-invasive investigations:

positive ETT at low stress
failure of maximal therapy
post MI angina

Question 8

name 2 drugs that a stent might elute

Answer 8

paclitaxel

sacrolimus

Question 9

Stents-bare metal vs drug eluting

Answer 9

Billion dollar industry
Very few good trials
No evidence of superiority (but $$$)
Next “big thing”-dissolving stents