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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
Why is the treadmill test not suitable for everyone
1. People can't walk 2. Unfit 3. Young females
26
When is a CT angiogram suitable
Excluding CAD in younger individuals
27
When is a CT angiogram unsuitable
People with arrhythmias and calcified disease
28
what is an issue with CT angiograms
Low Positive Predictive Value
29
What can an invasive angiogram show us
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
What is stress echo
Dynamic imagine with and without pharmacological stress Look for regional wall motion abnormalities
31
What is a SPECT/ myoview
Radio-labelled tracer Gives idea about degree of ischaemic MYOCARDIUM
32
How does SPECT work
Taken up by metabolising tissues
33
What does a 1st SPECT test show
Perfusion defects (looking at adenosine levels)
34
When would we bring a patient in for a second SPECT test
If there's a perfusion defect Fixed defect = scar Reversible = isichaemia
35
What is primary prevention of CAD
Reducing risk of CAD and risk factors We use SCORE tool which estimates 10 year risk of major CV even happening
36
What is secondary prevention of CAD
Risk factor modification Prognostic therapy Symptomatic therapy
37
Medications in primary prevention used to treat hypertension
Antihypertensives
38
Medications in primary prevention used to treat hypercholesterolaemia
Statins + Lipid modulating therapies
39
Medications in primary prevention used to treat T2DM
Diabetic therapy
40
Medications in primary prevention used to treat smoking
Cessation
41
Medications in primary prevention used to treat diet
General Advice
42
Medications in primary prevention used to treat excercise
Get Plenty
43
What are the three major arms of secondary prevention therapy
1. Lifestyle changes 2. Pharmacological 3. Interventional
44
What are lifestyle changes in secondary prevention
1. Risk factor and behaviour modification
45
What are pharmacological changes in secondary prevention
1. Reduce CV events (aspirin, statin) | 2. Reduce symptoms (nitrates)
46
What interventional changes in secondary prevention
1. Reduce events 2. Reduce symptoms PCI
47
What drug is given to patients in secondary pharmacological prevention
Beta blockers - Bisoprolol and atenolol
48
How do bisoprolol and atenolol function
Beta 1 receptors Reduce HR Reduce contractility (reduces O2 demand)
49
What are the side effect of beta-blockers like atenolol and bisoprolol
Tiredness, nightmares Bradycardia Erectile dysfunction Cold hands and feet
50
What are the contraindications for beta blockers
1. Asthma 2. Prinzmetal's angina 3. Severe heart block 4. Excess bradycardia
51
Why do we give patients nitrates
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
Why are calcium channel antagonists given
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
Name two second line abtianginal drugs
Nicorandil + Ivabridine
54
How does Nicorandil work
Veno and artero dilatory properties
55
How does Ivabridine work
Slows sinus rhythm
56
Why would anti platelets be given to a patient with angina
1. Aspirin is a cycle-oxygenase inhibitor 2. Decreased prostaglandin synthesis incl. thromboxane 3. Decreased platelet aggregation
57
Side-effect of aspirin
Gastric ulceration
58
Alternatives to aspirin
P2Y12 inhibitors (Clopidrgrel, prasugrel, ticagrel)
59
Why are statins given to patients with angina
Reduce LDL cholesterol
60
Why would we carry out revascularisation
1. Restore patent coronary arteries and increase flow
61
When would we carry out revascularisation
When medication fails or when high risk disease is identified
62
How would we carry out revascularisation
PCI (stenting) or Coronary artery bypass graft surgery
63
Pros of PCI vs CABG
1. Less invasive 2. Covenient 3. Repeatable 4. Acceptable
64
Cons of PCI vs CABG
1. Risk stent thrombosis 2. Risk restenosis 3. Can't deal with complex disease 4. Dual anti platelet therapy
65
Pros of CABG vs PCI
1. Prognosis | 2. Deals with complex diseases
66
Cons of CABG vs PCI
1. Invasive 2. Risk of stroke 3. Length of stay 4. Time for recovery

Year 2 (155 decks)

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