Heart Disease

Question 1

Long term consequences of coronary heart disease

Answer 1

Heart failure, arrhythmias

Question 2

Clinical diagnosis of angina

Answer 2

Visceral pain from myocardial hypoxia, characteristic patterns and characteristic background

Question 3

Gestures patients can use when describing pain in angina

Answer 3

Hands up to the chest or jaw, perhaps making a fist or imitating a squeezing motion

Question 4

Characteristic patterns in angina

Answer 4

Provocation - running for a bus, cold day, windy day, on exertion
Relief - goes away within a few minutes of stopping or by GTN use
Timing - only lasts a very short time

Question 5

Pain in angina

Answer 5

Pressing, squeezing, heaviness radiating to arm(s), back, jaw, teeth

Question 6

Emergency cases of chest pain and describe the pain

Answer 6

Myocardial infarction - severe, associated autonomic upset, ongoing pain despite >10mg morphine
Pulmonary embolism - breathlessness, dull (maybe pleuritic) pain
Dissection of aorta - tearing, excruciating pain which is severe then eases

Question 7

Pros and cons of exercise testing

Answer 7

Pros - cheap, reproducible, risk stratification

Cons - poor diagnostic accuracy in important sub-groups, sub maximal tests

Question 8

Pros and cons of perfusion imaging

Answer 8

Pros - non-invasive, more precision than exercise testing, risk stratification
Cons - radiation, false positives and negatives

Question 9

Pros and cons of CT angiography

Answer 9

Pros - non-invasive, anatomical data and risk stratification

Cons - radiation, costly, less precise than angiography, particularly when calcium present

Question 10

Describe the process of angiography

Answer 10

Sheath inserted into artery, catheter advanced from wrist/groin to coronary ostium, X-ray contrast agent injected to outline coronaries, video fluoroscopy recorded images in multiple views

Question 11

Pros and cons of angiography

Answer 11

Pros - gold standard, anatomical data and risk stratification, follow-on angioplasty
Cons - risk of stroke or death, radiation, contrast can cause renal dysfunction, rash or nausea

Question 12

Which tests would you perform on an older patient with typical symptoms of coronary heart disease?

Answer 12

Exercise tolerance test for test and angiography for management

Question 13

Drugs prescribed to reduce risk and relieve symptoms of coronary heart disease?

Answer 13

Aspirin, anti-platelet, beta blocker, statin, ACE inhibitor

Question 14

Lifestyle changes someone with coronary heart disease should make

Answer 14

Stop smoking, increase exercise, eat a good diet

Question 15

Revascularisation options for people with coronary heart disease

Answer 15

CABG, PCI

Question 16

Surgical technique for coronary artery bypass

Answer 16

• Performed under general anaesthetic
• Median sternotomy
• Long saphenous vein is harvested form leg or mammary artery from back of chest wall
• Patient is placed on cardio-pulmonary bypass
• Cardioplegia is given
• Patient stay overnight in ICU

Question 17

How long do patients stay in hospital after CABG?

Answer 17

7 days

Question 18

How long must patients stay off work after CABG?

Answer 18

2-3 months

Question 19

Complications of CABG

Answer 19

Death, stroke, MI, atrial fibrillation (at least 50% of patients), infection, cognitive impairment, sternal malunion, renal failure, failure to recover

Question 20

Complications of PCI

Answer 20

Death, stroke, MI, renal failure, bleeding, vascular complications, stent thrombosis, stent restenosis

Question 21

PCI technique

Answer 21

• Vascular access - tube in artery
• Anti-platelet drugs, anticoagulation (pre treatment)
• Catheter to ostium of coronary
• Guidewire down vessel
• Balloons threaded over wire
• Stent(s) implanted
• Balloon, catheter and wires removed

Question 22

Indication for angiography

Answer 22

Patient must have severe symptoms and be high risk (STEMI - immediate PCI <30 mins of hospital arrival, STEMI - during hospital admission, high risk stable patients)

Question 23

What must the patient have to be suitable for revascularisation?

Answer 23

Multi-vessel disease, left main disease, diabetes, comorbidities

Question 24

What could go wrong in angiography?

Answer 24

Stroke, contrast nephropathy, bleeding, failure of stent (to deliver, to expand, expand without perforation, to remain patent, to treat and prevent future events)

Question 25

Pros and cons to using radial artery access compared to brachial/femoral access

Answer 25

Pros - dual supply to hand, superficial, compressible, no adjacent nerve/vein
Cons - smaller, prone to spasm, occlusion occurs in 5%