IHD

Question 1

What is prinzmetal angina? RF? Triggers? Syx? Ix? Mx?

Answer 1

• Rare + severe anginal CP due to coronary artery spasm. Typically presents in younger
• RF = smoking, migranes, raynaud’s phenomenon, Japanese NOT HTN/atheroma
• Triggers = illicit drugs, triptans, aspirin, BB, artery instrumentation e.g. angiography

Syx
- CP usually between midnight and morning while asleep or resting.
- nauseous
- dizzy
- sweating

Ix
- Bloods: FBC, UE, glucose, lipids, troponins
- Imaging: CXR, ECHO
- ECG: transient ST elevation
- Angiography: evidence of coronary vasospasm
- Stress Test: exercise-induced spasm with ECG changes for ischaemia h/e many pts have negative findings

Mx
- Avoid triggers, triptans, BB, aspirin, illicit drugs
- Smoking cessation
- Healthy lifestyle
- Manage stress
- GTN PRN
- CCB +/- long acting nitrates

Question 2

What is anginal pain? what are associated syx?

Answer 2

Anginal pain (All 3 = typical angina, 2 = atypical angina, 0-1 features =non-anginal CP):
(1.) Constricting/heavy discomfort to chest, neck, shoulders, jaw, arms
(2.) Precipitated by exertion (exercise, emotion, cold weather, heavy meal)
(3.) Relieved by rest or GTN

Associated Syx
(1.) Nausea
(2.) Sweating
(3.) Dyspnoea
(4.) Breathlessness

NOTE: Stable angina pain is precipitated by predictable factors whereas unstable angina occurs at any time and should be managed as ACS.

Question 3

Ix of stable angina

Answer 3

(1.) Bloods
o FBC
o UE
o Lipids
o TFT
o HbA1c
o Troponin
o LFTs before starting statins

(2.) ECG

(3.) Imaging: CXR, ECHO

(4.) Special tests for IHD
o Myocardial Perfusion MRI
o Exercise ECG
o CT Coronary Angiography (1st line for ruling out CAD)
o Radiocontrast Coronary Angiography
o Stress echo

Question 4

Mx of stable angina

Answer 4

R - Refer to cardiology (urgently if unstable)

A - Advise them about dx, management and when to call an ambulance.
- Education and lifestyle: cut down smoking, weight exercise, diet

M - medical rx
(1.) GTN. SE: headache, dizziness, postural hypotension. Repeat after 5mins if pain not subsided h/e if after 10mins call for ambulance if pain persists

(2.) BB (1st line) or CCB/amlodipine or both or Long-acting nitrates, ivabradine, nicorandil, ranolazine

(3.) Aspirin, Atorvastatin, ACEi for secondary CVD prevention

Risk Assessment of IHD
- QRISK = calculates chance of heart attacks/stroke over next 10y
- JBS3 = CVD risk

Question 5

NSTEMI vs STEMI pathophysiology

Answer 5

NSTEMI
a. Partial ischaemia usually distally
b. Necrosis of <50% of the myocardial wall
c. ST depression

Transmural/STEMI
a. Complete artery occlusion. total infarction distally and proximally
b. ST elevation

Question 6

ACS: Syx + IX (inc ECG territory)

Answer 6

(1.) Acute central crushing CP lasts >20mins
- May radiate to arms, back or jaw
- Pain at rest + worsening

(2.) N+V
(3.) Sweating
(4.) Dyspnoea
(5.) Palpitations
(6.) ‘Silent MI’ - CP not present in elderly, DM. Some ethnic groups may present with atypical pains. May present w/ syncope, pulmonary oedema, epigastric pain, vomiting

Investigations
(1.) Bloods:
- FBC, UE, lipids, CRP, glucose
- Troponins tested 6 + 12hr after pain onset. Differentiates between NSTEMI (raised) + unstable angina (normal)

(2.) ECG
- STEMI = ST elevation + new LBBB
- NSTEMI = ST depression or T-wave inversion or pathological Q wave
- Anterior (LAD) = V1-4
- Lateral (circumflex) = I, aVL, V5-6
- Inferior (RCA) = II. III, avF

(3.) CXR

(4.) ECHO - May be useful in identifying precipitants for ischaemia - eg, ventricular hypertrophy and valvular disease

(5.) Coronary angiography (GOLD) - assesses CAD

Question 7

ACS Mx: acute + secondary prevention

Answer 7

Acute: MONA
- Morphine
- Oxygen if <94%
- Nitrates (GTN)
- Aspirin 300mg STAT
- 12-lead ECG do not delay transfer

STEMI Mx: ST elevation + raised troponin
(1.) Urgent revascularisation
- PCI: Syx onset <12hrs, PCI must be delivered within 2hrs following first medical contact
- Thrombolysis if PCI not available
(2.) Fondaparinux

NSTEMI Mx: ECG changes + raised troponin
(1.) Immediate-high GRACE (6m mortality) = angiography +/- PCI within 96hrs
(2.) LMWH or fondaparinux

Secondary prevention
- Lifestyle: smoking cessation, reduce alcohol, optimise comorbidities
- Medical (6As)
(a.) Aspirin 75mg
(b.) Antiplatelet: clopidogrel or ticagrelor for 12m. Dual antiplatelet if PCI + stenting.
(c.) Atorvastatin 80mg
(d.) ACEi
(e.) Atenolol - titrated as high as tolerated
(f.) Aldosterone antagonist for HF pts

Question 8

Complications of MI (DREAD)

Answer 8

• Death
• Rupture of heart septum or papillary muscles
• Edema aka HF
• Arrythmia and aneurysm
• Dressler syndrome (pericarditis that occurs 2-3w post-MI)