IHD (including angina and ACS) Flashcards
what clinical features suggest serious causes of chest pain?
Respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
Altered level of consciousness.
High temperature (especially if it is higher than 38.5°C).
how should a patient with chest pain and suspected ACS be treated?
Treat pain with glyceryl trinitrate (GTN) and/or an opioid (for example intravenous diamorphine 2.5 mg to 5.0 mg, given slowly over 5 minutes).
Give aspirin 300 mg (unless there is clear evidence that the person is allergic to it). Send a written record with the person that aspirin has been given.
Take a resting 12-lead ECG (electrocardiogram). Send the results to the hospital. Recording and sending the ECG should not delay transfer to hospital.
how should a patient with chest pain and suspected pulmonary oedema be treated?
Give an intravenous diuretic (for example furosemide 40 mg to 80 mg, given slowly).
Give an intravenous opioid (for example diamorphine 2.5 mg to 5.0 mg, given slowly over 5 minutes).
Give an intravenous anti-emetic (for example metoclopramide 10 mg). This can be mixed with diamorphine.
Give a nitrate, either sublingually or buccally (for example GTN spray, two puffs).
how is a tension pneumothorax treated?
if the person’s condition is life threatening:
Consider inserting a large-bore cannula through the second intercostal space in the mid-clavicular line, on the side of the pneumothorax.
how do people with stable angina usually present?
- Precipitated by physical exertion.
- Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
- Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
Atypical angina presents with two of the above features.
In addition, atypical symptoms include gastrointestinal discomfort, and/or breathlessness and/or nausea.
how should people with newly diagnosed angina be managed?
Explain the diagnosis of stable angina to the person. The explanation should include:
Factors that can provoke angina, such as exertion, emotional stress, exposure to cold, or eating a large meal.
Explore and address any misconceptions the person might have about their angina. This includes:
- Implications for daily activities.
- Risk of myocardial infarction.
- Life expectancy.
Advise the person to seek medical help if there is a sudden worsening in the frequency or severity of their angina.
Discuss the reasons for treatment, benefits and adverse effects (such as flushing, headache, and light-headedness).
Provide information on how to use a short-acting sublingual nitrate and when to administer it.
Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke.
how should a person with angina be reviewed?
Review the person every 6 months to 1 year depending on the stability of their angina and their comorbidities.
Check for ongoing symptoms of angina (at rest or with exercise)
If the person is taking anti-anginal treatment but has persistent symptoms give advice on further treatment and referral.
Assess cardiovascular disease risk and identify any modifiable cardiovascular risk factors.
Check HR and BP and Screen for low mood or depression.
Check for signs and symptoms of heart failure (for example breathlessness, fatigue, or ankle swelling).
If the person is taking treatment for symptom control, ensure that they are taking a beta-blocker or a calcium-channel blocker (unless both are contraindicated or not tolerated).
Ensure that the person is taking drugs for secondary prevention as appropriate.
Check compliance, and identify and manage drug interactions and complications of treatment.
Explain when to seek further medical advice (such as worsening symptoms).
How should I manage a person with uncontrolled angina symptoms?
People on monotherapy
- Ensure that the person is taking the maximum licensed or highest tolerated dose.
If the person is taking a beta-blocker:
- Switch to, or add, a long-acting dihydropyridine calcium-channel blocker (CCB), such as amlodipine, modified-release nifedipine, or modified-release felodipine.
- Do not combine a beta-blocker with a rate-limiting CCB (diltiazem or verapamil), as severe bradycardia and heart failure can occur.
- If a dihydropyridine CCB is contraindicated or not tolerated, consider adding a nitrate,
If the person is taking a CCB:
- Switch to or add a beta-blocker.
- Do not combine a beta-blocker with a rate-limiting CCB (diltiazem or verapamil), as severe bradycardia and heart failure can occur.
- If a beta-blocker is contraindicated or not tolerated, consider adding a nitrate, nicorandil, ivabradine, or ranolazine (consider seeking specialist advice when initiating ivabradine or ranolazine).
how is Unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) managed initially?
- oxygen
- Nitrates are used to relieve ischaemic pain. If sublingual glyceryl trinitrate is not effective, intravenous or buccal glyceryl trinitrate or intravenous isosorbide dinitrate is given. If this isnt effective, can give morphine, but give anti emetic with it.
- asprin
- clopidogrel
what is the secondary prevention for MI’s?
- lifestyle changes
- stop smoking
- advise physical activity and weight
what is heart failure with preserved ejection fraction?
If the heart muscle is too weak, the condition is known as heart failure with a reduced ejection fraction (HFrEF).
Ejection fraction is used to assess the pump function of the heart; it represents the percentage of blood pumped from the left ventricle (the main pumping chamber) per beat. A normal ejection fraction is greater than or equal to 50 percent. There are many causes for a weak heart muscle (low ejection fraction).
If the heart pumps normally but is too stiff to fill properly, the condition is known as heart failure with preserved ejection fraction (HFpEF).
what is heart failure with reduced ejection fraction?
Heart failure with reduced ejection fraction happens when the muscle of the left ventricle is not pumping as well as normal. The ejection fraction is 40% or less.footnote1
The amount of blood being pumped out of the heart is less than the body needs. A reduced ejection fraction can happen because the left ventricle is enlarged and cannot pump normally (e.g left ventricular hypertrophy, cardiomyopathy, aortic stenosis, mitral regurg)
What does a high NT proBNP mean?
If your BNP or NT-proBNP levels were higher than normal, it probably means you have heart failure.
If NT-proBNP > 2,000 ng/l (236 pmol/l), refer urgently within 2 weeks
Heart failure is then confirmed with echo
how is heart failure with preserved ejection fraction managed in comparison to heart failure with reduced EF?
HFpEF
- Manage comorbidities such as hypertension, atrial fibrillation, ischaemic heart disease and diabetes in line with NICE guidance
- Offer a personalised exercise based cardiac rehabilitation programme unless condition is unstable
HFrEF
- Offer:
• ACEI* and BB
• an MRA* if symptoms continue - consider ARB* if intolerant of ACEI
- Offer a personalised exercise based cardiac rehabilitation programme unless condition is unstable
- If symptoms persist despite first-line treatment,
seek specialist advice
what is the most common underlying cause for HF?
coronary artery disease
