HF and CAD Flashcards
What to ask when taking a patient’s history?
Ask about
Anginal symptoms
Past heart attacks
PCI/ surgical revascularisation
Risk factors for CAD
Type 2 DM, smoking, hypertension, hypercholesterolaemia, family history, peripheral vascular disease
Traditional clinical classifications of suspected anginal symptoms?
Typical angina - meets 3 of following characteristics; constricting discomfort in front of chest or in neck, jaw, shoulder or arm; precipitated by exertion; relieved by rest or nitrates within 5 mins
Atypical angina - meets two of those characteristics
Non-anginal CP - meets only one or none of these characteristics
What is myocardial ischaemia?
mismatch between myocardial oxygen demand and myocardial blood supply
When is revascularisation indicated in patients with heart failure
To treat an acute coronary syndrome
For symptomatic relief of angina
If patient requires other cardiac surgery e.g aortic valve replacement
How to test for myocardial viability?
Stress echo – wall thickness, and biphasic response to dobutamine stress predict improvement with response to revascularisation
Cardiac MRI – Dobutamine stress and volume of scar predict response to revascularisation
Nuclear imaging - assess ischaemia and cellular integrity to predict response. PET imaging best specificity
What is myocardial viability?
cardiomyocytes that are alive by cellular, metabolic and microscopic contractile function
What is hibernating myocardium?
dysfunctional myocardium at rest but with cardiomyocytes that are alive, and the potential to recover with improved blood flow
What is stunned myocardium?
decreased contractile function due to transient hypoperfusion with normal resting flow
What bloods to test for?
Full blood count ? Anaemia
Thyroid function tests
Lipid profile
Blood glucose, HbA1C
Renal function
Uric acid
What to check for when doing patient exam?
Blood pressure
Xanthelasma, tendon xanthoma
Carotid bruit
Absent/weak peripheral pulses
Heart murmur ? Aortic stenosis
Traditional clinical classifications of suspected anginal symptoms?
Typical angina - meets 3 of following characteristics; constricting discomfort in front of chest or in neck, jaw, shoulder or arm; precipitated by exertion; relieved by rest or nitrates within 5 mins
Atypical angina - meets two of those characteristics
Non-anginal CP - meets only one or none of these characteristics
Medical therapies - use of antianginal meds in pts with CCS and HFrEF
Beta blockers – treatment for both heart failure and angina
-> persistence of CCS symptoms -> (2)
-> HR >- 70bpm, and SR -> Ivabradine -> in absence of improvement ->
-> HR <70bpm, and/or AF -> Trimetazidine OR Ranolazine; Nicorandil or Nitrates; Felodipine OR amlodipine
Give all standard heart failure therapies
Statins in HF
Studies show minimal benefits
Anticoagulants/ antiplatelets
Aspirin – May interfere with renin – angiotensin blockade. Risk of GI bleeds, renal dysfunction.
Warfarin – indicated in AF, left ventricular thrombus. No benefit in patients with sinus rhythm
Novel oral anticoagulants – COMMANDER-HF study- No benefit of low dose rivaroxaban in patients with heart failure and CAD.
Implantable Cardioverter Defibrillators
Indicated in patients with heart failure EF < 35%
Patients with ischaemic cardiomyopathy at greater risk of ventricular arrhythmias
Wait until 3 months after MI or revascularisation, ensure on optimal medical therapy
Scar burden may be useful in predicting risk of sudden cardiac death
Conclusion:
CAD remains the most common cause of heart failure
Clues to diagnosis in history and assessment
Various methods to assess ischaemia and viability, no clear gold standard
Benefit of revascularisation in patients without angina remains unclear
Optimising pharmacological therapies mainstay of treatment
Consider ICD if EF <35% despite optimal therapies
