IHD tutorial

Question 1

what are the cardiac causes of severe chest pain?

Answer 1

• -Acute coronary syndrome
• -Unstable angina
• -NSTEMI
• -STEMI
• -Coronary spasm
• -Coronary dissection
• -Cocaine abuse
• -Pericarditis

Question 2

what are the pulmonary causes of severe chest pain?

Answer 2

• -Pulmonary embolus

- -Pneumonia

Question 3

what are the GI causes of severe chest pain?

Answer 3

• -Gastro-oesophageal reflux

- -Cholecystitis

Question 4

other causes of severe chest pain except for cardiac/pulmonary/GI?

Answer 4

1) Chest Wall
- -Costochondritis
2) Large Vessel
- -Aortic dissection

Question 5

What investigations should be immediately performed in the Emergency Department on a patient with severe chest pain?

Answer 5

1) 12 lead ECG
2) Rapid Assay Cardiac biomarkers (Troponin or Creatine Kinase)
3) Other Blood tests
- -Full blood count
- -Renal function & electrolytes
- -Liver function tests
- -Coagulation profile
- -Fasting risk factors
4) Chest X-ray
5) Echocardiography (only if residual diagnostic doubt)

Question 6

what should be looked at ECG?

Answer 6

1) Rate
2) Rhythm
3) Axis
4) Intervals
- -PR interval
- -QRS duration
- -QT interval
5) Morphology
- -P wave
- -QRS complex morphology
- -ST segment – elevation, depression
- -T Wave
- -U wave
- -Voltage criteria for hypertrophy

Question 7

Marked ST-elevation I, aVL, V1-V5 andST depression II, III, aVF signifies?

Answer 7

anterolateral MI

Question 8

what is the role of troponin in the diagnosis of ACS?

Answer 8

• -Cardiac-specific with high sensitivity for myocardial ischemia
• -The degree of elevation often correlates with the size of the infarct.
• -High sensitivity troponin assays (HscTn) may detect an increase in serum troponin level as early as 90 to 180 minutes after myocardial ischemia has occurred
• -Can also be elevated in other cardiac and noncardiac conditions: See differential diagnosis of increased troponin below.

Question 9

does CK-MB still used in the diagnosis of ACS?

Answer 9

Yes

• -CK-MB is more specific to cardiac tissue than total CK.
• -Can be helpful for evaluating reinfarction because of its short half-life but is no longer commonly used
• -The degree of elevation often correlates with the size of the infarct.

Question 10

Troponin T vs CK-MB?

Answer 10

Serum troponin T is the most important cardiac-specific marker and may be measured 3–4 hours after the onset of myocardial infarction. CK-MB values correlate with the size of the infarct, reach a maximum after approximately 12–24 hours, and normalize after only 2–3 days, making CK-MB a good marker for evaluating reinfarction.

Question 11

What treatments should be commenced immediately in the ED?

Answer 11

• -Intravenous opioids (Morphine 4-8mg) for relief of pain and anxiety.
• -Oxygen (2-4l/minute) indicated in patients with hypoxemia (SaO2 < 90%). Hence no oxygen indicated for this patient.
• -Glyceryl Tri-Nitrate, to assess for any reversibility of myocardial ischaemia. and for symptom relief
• -DAPT (Dual Antiplatelet Therapy)
  1) Aspirin 150-325 mg (chewable)
  2) Prasugrel or Ticagrelor
• -Statin – for plaque stabilization
• -Benzodiazepam – A mild tranquilliser to be considered in very anxious patients (especially useful in patients with ACS due to cocaine use)

Question 12

what pharmacologic treatment is required in patients with MI?

Answer 12

1) Sublingual or intravenous nitrate (nitroglycerin or ISDN)
- -For symptomatic relief of chest pain
- -Does not improve prognosis
- -Contraindications: inferior wall infarct (due to risk for hypotension), hypotension, and/or PDE 5 inhibitor (e.g., sildenafil) taken within last 24 hours
2) Morphine IV or SC (3–5 mg)
- -Only if the patient has severe, persistent chest pain or severe anxiety related to the myocardial event
- -Administer with caution due to increased risk of complications (e.g., hypotension, respiratory depression) and adverse events
3) Beta-blocker
- -Recommended within the first 24 hours of admission
- -Avoid in patients with hypotension, features of heart failure, and/or risk of cardiogenic shock (e.g., large LV infarct, low ejection fraction).
4) Statins: early initiation of high-intensity statin (such as atorvastatin 80 mg) regardless of baseline cholesterol, LDL, and HDL levels
5) Loop diuretic (e.g., furosemide) if the patient has flash pulmonary edema or features of heart failure

Question 13

Would you have arranged reperfusion therapy for patients with STEMI?

Answer 13

Any patient with ST elevations on ECG requires immediate evaluation for urgent revascularization. The administration of other therapies should not delay care.

Question 14

what are the indications of fibrinolytic therapy?

Answer 14

• -If PCI cannot be performed < 120 minutes after onset of STEMI
• -If PCI was unsuccessful
• -No contraindications to thrombolysis

Question 15

what are the indications of reperfusion therapy?

Answer 15

1)History of chest pain/discomfort of <12 h (clinical presentation compatible with MI)
and
2)Persistent ST-segment elevation or non-interpretable ST segment on ECG (
–Presumed) new left (or right) bundle-branch block
–Ventricular pacing

Question 16

PCI is contraindicated in cardiogenic shock (low BP and poor tissue perfusion). T/F

Answer 16

False

• -Note: primary PCI also indicated for patients
• -In cardiogenic shock (low BP and poor tissue perfusion)
• -With contraindications to fibrinolytic therapy irrespective of time delay
• -With ongoing or recurrent pain and dynamic ECG changes irrespective of time delay

Question 17

does a patient with ECG findings of LBBB and symptoms of MI but no ST elevations need to be reperfused?

Answer 17

Yes
An acute left bundle branch block accompanied by symptoms of the acute coronary syndrome is also considered an ST-elevation myocardial infarction (STEMI) because ST elevations cannot be adequately assessed in the setting of an LBBB.

Question 18

what are the absolute contraindications of fibrinolysis?

Answer 18

• -Haemorrhagic stroke or stroke of unknown origin at any time
• -Ischaemic stroke in preceding 6 months
• -Central nervous system trauma or neoplasms
• -Recent major trauma/surgery/head injury (within preceding 3 weeks)
• -Gastrointestinal bleeding within the last month
• -Known bleeding disorder
• -Aortic dissection
• -Non-compressible punctures (e.g. liver biopsy, lumbar puncture)

Question 19

what are the relative contraindications of fibrinolysis?

Answer 19

• -Transient ischaemic attack in preceding 6 months
• -Oral anticoagulant therapy
• -Pregnancy or within 1 week post-partum
• -Refractory hypertension (systolic BP >180 mmHg and/or diastolic BP >110 mmHg)
• -advanced liver disease
• -Infective endocarditis
• -Active peptic ulcer
• -Refractory resuscitation

Question 20

what anticoagulants are needed for patients undergoing PCI?

Answer 20

• -Patients undergoing PCI should receive DAPT (aspirin and a P2Y12 inhibitor), and a parental anticoagulant (Unfractionated heparin, enoxaparin or bivalirudin)
• -GP IIb/IIIa receptor antagonist (e.g., eptifibatide or tirofiban): should be considered in pre-catheterization setting

Question 21

what medications are necessary post-MI before discharge?

Answer 21

• -Dual Antiplatelet Therapy
  1) Aspirin 75-325mg daily (forever)
  2) Ticagrelor or Prasugrel (X12 months)
• -Beta-Blockade eg bisoprolol 5 mg daily
• -Statin therapy (rosuvastatin 20 mg, pravastatin 40 mg or atorvastatin 10 mg daily)
• -ACE-inhibition or if intolerant angiotensin receptor blockade

Question 22

in what setting beta-blockers will be CI after MI?

Answer 22

Beta-blockers contraindicated, because of asthma. Non-dihydropyridine calcium antagonists (Verapamil or Diltiazem) could be considered for additional CV protection.