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Year 2 > IHD Symposium -Stable IHD > Flashcards

IHD Symposium -Stable IHD Flashcards

1
Q

What are the epicardial coronary vessels

A

Left and right coronary blood vessels because they sit on the heart surface

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2
Q

What symptom is caused by restricted coronary blood flow

A

Angina - almost always an effect of atherosclerosis

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3
Q

What is ischaemia

A

Mismatch between oxygen demand and oxygen supply

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4
Q

How does O2 supply demand mismatch occur in ischaemia

A
  1. Proximal arterial stenosis impairs blood flow
  2. Impairs distal resistance
  3. Reduced oxygen-carrying capacity of blood
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5
Q

By how much does the diameter have to decrease before symptoms of angina and ischaemia arise

A

Below 75% its original size

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6
Q

What determines the resistance of the epicardial arteries

A

The resistance of the microvascular vessels

If there is a LOW pressure in epicardial and HIGH in microvascular - low flow (3 ml/s - normal flow rate)

If there is a LOW pressure in epicardial and LOW in microvascular - high flow

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7
Q

When does resistance in microvascular vessels decrease and why is this necessary

A

During excersise

To supply the heart with more oxygen

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8
Q

How does epicardial disease effect the coronary arteries and how does it effect flow

A

Increases resistance in the epicardial vessels

Flow remained at 3 ml/s as microvascular resistance reduces (homeostasis)

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9
Q

Under what conditions can compensation of pressure no longer keep flow rate at 3 ml/s

A

During stenosis of epicardial arteries

Microvascular resistance can be lowered anymore

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10
Q

How does stenosis effect the heart

A

Myocardium becomes ischaemic and pain is experienced

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11
Q

How is IHD stopped after excersise

A

Rest

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12
Q

What is Prinzmetal’s angina

A

Coronary spasms

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13
Q

What is microvascular angina (syndrome X)

A

Microvascular vessels narrow which leads to hypoxia

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14
Q

What is Crescendo angina

A

Unstable angina - it changes or worsens after a period of time and/or occurs at rest

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15
Q

What would patients present with if they had angina

A
  1. Heavy, central, tight radiation to arms, jaw and neck
  2. Made worst by exertion
  3. Relieved by Rest or GTN
3/3 = typical agina
2/3 = atypical pain 
1/3 = non-anginas pain
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16
Q

What can angina be mistaken for

A 
Pericarditis/ Myocarditis
Pulmonary embolism 
Chest infection 
Dissection of aorta
Gastro-oesophageal reflux
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17
Q

What signs should we be looking for when diagnosing a patient for angina

A
  1. Hypercholesterolaemia
  2. Smoking
  3. Diabetes
  4. High BP

Scares from surgery (e.g. pacemakers)

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18
Q

How does an ECG help diagnosis of angina

A

12 Lead ECG - should be normal but could give us clues of IHD (T-wave inversions)

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19
Q

How does an Echocardiogram help diagnose for angina

A

Normal

Allows us to check LV function and see signs of previous infarcts (alternative diagnosis)

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20
Q

How do we initially manage patients with suspected SCAD (spontaneous Coronary Artery disease)

A
  1. Assess PTP (pre-test probability)
  2. Low PTP < 15%
  3. Intermediate (15-85%)
  4. High PTP (diagnosis of SCAD)
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21
Q

Two anatomical diagnostics for angina

A

CT angiography

Invasive Angiography

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22
Q

What does a CT angiography show us

A

Shows us all the vessels of the body (saggital cross-section) - narrowed vessels

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23
Q

What is the physiological diagnostic investigation for angina

A
  1. Exercise stress treadmill
  2. Stress echo
  3. Perfusion MRI
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24
Q

What is the treadmill test

A

Induce ischaemia while walking uphill incrementally fast

Look at ST segment - if depressed then that detects a late stage of ischaemia

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25
Q

Why is the treadmill test not suitable for everyone

A
  1. People can’t walk
  2. Unfit
  3. Young females
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26
Q

When is a CT angiogram suitable

A

Excluding CAD in younger individuals

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27
Q

When is a CT angiogram unsuitable

A

People with arrhythmias and calcified disease

28
Q

what is an issue with CT angiograms

A

Low Positive Predictive Value

29
Q

What can an invasive angiogram show us

A

Pressure gradient across the stenosis of the artery (going from 100 mmHg on one side of stenosis to 80 mmHg on the other side e.g.)

30
Q

What is stress echo

A

Dynamic imagine with and without pharmacological stress

Look for regional wall motion abnormalities

31
Q

What is a SPECT/ myoview

A

Radio-labelled tracer

Gives idea about degree of ischaemic MYOCARDIUM

32
Q

How does SPECT work

A

Taken up by metabolising tissues

33
Q

What does a 1st SPECT test show

A

Perfusion defects (looking at adenosine levels)

34
Q

When would we bring a patient in for a second SPECT test

A

If there’s a perfusion defect

Fixed defect = scar
Reversible = isichaemia

35
Q

What is primary prevention of CAD

A

Reducing risk of CAD and risk factors

We use SCORE tool which estimates 10 year risk of major CV even happening

36
Q

What is secondary prevention of CAD

A

Risk factor modification
Prognostic therapy
Symptomatic therapy

37
Q

Medications in primary prevention used to treat hypertension

A

Antihypertensives

38
Q

Medications in primary prevention used to treat hypercholesterolaemia

A

Statins + Lipid modulating therapies

39
Q

Medications in primary prevention used to treat T2DM

A

Diabetic therapy

40
Q

Medications in primary prevention used to treat smoking

A

Cessation

41
Q

Medications in primary prevention used to treat diet

A

General Advice

42
Q

Medications in primary prevention used to treat excercise

A

Get Plenty

43
Q

What are the three major arms of secondary prevention therapy

A
  1. Lifestyle changes
  2. Pharmacological
  3. Interventional
44
Q

What are lifestyle changes in secondary prevention

A
  1. Risk factor and behaviour modification
45
Q

What are pharmacological changes in secondary prevention

A
  1. Reduce CV events (aspirin, statin)

2. Reduce symptoms (nitrates)

46
Q

What interventional changes in secondary prevention

A
  1. Reduce events
  2. Reduce symptoms

PCI

47
Q

What drug is given to patients in secondary pharmacological prevention

A

Beta blockers - Bisoprolol and atenolol

48
Q

How do bisoprolol and atenolol function

A

Beta 1 receptors

Reduce HR

Reduce contractility

(reduces O2 demand)

49
Q

What are the side effect of beta-blockers like atenolol and bisoprolol

A

Tiredness, nightmares

Bradycardia

Erectile dysfunction

Cold hands and feet

50
Q

What are the contraindications for beta blockers

A
  1. Asthma
  2. Prinzmetal’s angina
  3. Severe heart block
  4. Excess bradycardia
51
Q

Why do we give patients nitrates

A
  1. Venodilators
  2. Reduces venous return + preload on the heart
  3. Reduce work done by the heart and O2 demand

Dilate coronary arteries and antagonise spasms

52
Q

Why are calcium channel antagonists given

A

Primary arterodilatoes

Reduces BP in systemic arteries

Reduction of after load on heart

Less energy required to produce same CO

Reduced Work Done and O2 demands

Antagonise spasms of coronary arteries by dilating them

53
Q

Name two second line abtianginal drugs

A

Nicorandil + Ivabridine

54
Q

How does Nicorandil work

A

Veno and artero dilatory properties

55
Q

How does Ivabridine work

A

Slows sinus rhythm

56
Q

Why would anti platelets be given to a patient with angina

A
  1. Aspirin is a cycle-oxygenase inhibitor
  2. Decreased prostaglandin synthesis incl. thromboxane
  3. Decreased platelet aggregation
57
Q

Side-effect of aspirin

A

Gastric ulceration

58
Q

Alternatives to aspirin

A

P2Y12 inhibitors (Clopidrgrel, prasugrel, ticagrel)

59
Q

Why are statins given to patients with angina

A

Reduce LDL cholesterol

60
Q

Why would we carry out revascularisation

A
  1. Restore patent coronary arteries and increase flow
61
Q

When would we carry out revascularisation

A

When medication fails or when high risk disease is identified

62
Q

How would we carry out revascularisation

A

PCI (stenting) or Coronary artery bypass graft surgery

63
Q

Pros of PCI vs CABG

A
  1. Less invasive
  2. Covenient
  3. Repeatable
  4. Acceptable
64
Q

Cons of PCI vs CABG

A
  1. Risk stent thrombosis
  2. Risk restenosis
  3. Can’t deal with complex disease
  4. Dual anti platelet therapy
65
Q

Pros of CABG vs PCI

A
  1. Prognosis

2. Deals with complex diseases

66
Q

Cons of CABG vs PCI

A
  1. Invasive
  2. Risk of stroke
  3. Length of stay
  4. Time for recovery

Year 2 (155 decks)

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