Ischaemic Heart Disease

Question 1

Stable and Unstable angina

STEMI and NSTEMI

Answer 1

Stable angina = Chest pain brought on by exercise/motion and relieved by rest, negative trops and no ECG changes

Unstable Angina = pain comes on at unpredictable intervals, at rest. negative trops and no ECG changes

STEMI = positive trops, ST elevation on ECG 
NSTEMI = Positive trops, no ST elevation

Question 2

History to take

Answer 2

SOCRATES

• acute, constant pain not worsened by breathing and radiates to the jaw and arm.
• associated nausea, vomiting, dyspnoea and diaphoresis
• reduced ET
• worse with exercise and relieved by GTN
• Hx of similar pain

Question 3

Background to ask of

Answer 3

Admissions to Hospital
Investigations - ECG, ETT, ECHO, Angio
Treatments given - angioplasy, thrombolysis, grafting
Medications on/started?
Complications - arrhythmias? Cardiac Faiure? Further angina
participation in cardiac rehab programme?

Question 4

Rx factors for CVD? Control of these?

Answer 4

Previous IHD/Angina 
Hyperlipidaemia
DM 
HTN
FHx
Smoking
Use of OCP
Obesity
Physical activity

Control:
- P, NP, success so far?

Question 5

Examination findings?

Answer 5

BP
Murmurs - Valvular disease
Signs of cardiac failure - oedema, heave, apex displacement, raised JVP, orthopnea, bibasal crackles
Signs of rhythm disturbance - AF?

Question 6

Differential diagnosis?

Answer 6

GORD?
Oesophageal spasm?
MSK?
PE?
Acute pericarditis?
Pneumonia?

Question 7

Investigations to complete?

Answer 7

ECG - current or old changes
Troponins - 6h apart
Bloods: FBC, UEC,TFT, Lipids, HbA1C
CXR
ETT
ECHO 
Angiogram (or CT angiography in younger people which is less invasive however if there is calcification of the vessels then it's hard to interpret)

Question 8

Management - immediate

Answer 8

Stable angina - treat with GTN +/- BBlockers

Unstable Angina - Aspirin, GTN, BBlockers
- Consider angiography +/- plasty

STEMI 
- Morphine, O2, nitrate, DAPT, antiemetics = admit CCU for continuous ECG + PCI/angioplasty. (thrombolyse if transfer >3h)
tPA/tenectplase < 85 years 
streptokinase if > 85 years
ACEi and BBlocklers for long term

NSTEMI
- morphone, O2, short acting nitrates, DAPT, anti-emetics (metocloperamide). admit to CCU for telemtry
early revasc not as important < 24h
ACEi and BBlockers for long term

Question 9

MI complications?

Answer 9

Arrhythmia
Bradycardia
Heart Failure
Further Ischaemia

Question 10

Secondary prevention

Answer 10

NP
- diet, physical activity, smoking cessation, cardiac rehab programme

P

• BP lowering = ACEi
• Statin
• Antiplatelet (aspirin forever and ticag for 12/12)
• Anti-anginal (BBlockers, Diltiazem, Nitrates)

Surg
- CABG in 3 vessel disease with LV damage, L main coronary stenosis or proximal LAD stenosis