Ischaemic Heart disease

Question 1

See ACS for that side of IHD

Question 2

What is ishcaemic HD

Answer 2

Angina + ACS

Question 3

Causes of angina

Answer 3

Coronary artery vasospasm
Microvascular dysfunction - impaired function of microvasculature
Extracoronary factors - aortic stenosis, HOCM, significant anaemia

Question 4

Pathophysiology of angina

Answer 4

Atherosclerosis -> plaque rupture -> thrombus formation -> endothelial dysfunction -> imbalance oxygen demand and supply

Inflammatory mediatros eg cytokines, genetics

Question 5

Angina features

Answer 5

Chest pain - This may not be present in elderly or diabetic patients
Dyspnoea
A minority of patients may complain of dyspnoea rather than chest pain. This is sometimes termed ‘equivalent’ angina
Patients may also describe nausea, lightheadedness and fatigue

Question 6

NICE definition of aninal chest pain criteria - typical, atypical and non anginal chest pain

Answer 6

all 3 = typical
2 = atypical
1 or none = non anginal

-Constricting discomfort on fortn of chest, neck, shoulder, jawa or arms
Precipitated by physical exertion
Relieved by GTN in 5 mins

Question 7

Investigations for angina which cant be excluded by physical assessment

Answer 7

1st line - CT coronary angiography
2nd line - non invasive functional imaging (looking for reversible MI)
3rd line - invasive coronary angiography

Question 8

Non invasive functional cardiac imaging

Answer 8

Myocardial perfusion scntigraphy w single photon emission CT - MPS w SPECT
Stress ECHO
First pass contrast enhanced MR perfusion
MR imaging for stress induced wall motion abnormalities

Question 9

Medication for angina

Answer 9

Aspirin and statin in absence of CI
Sublingual glyceryl tinitate (GTN) for anginal attacks
CCB, beta blocker first line monothearpy - if not controlled add in the other
Add third drug while waiting for PCI or CABG

Question 10

What CCB use in angina monotherapy vs w beta blocker

Answer 10

Monotherapy - Rate limiting one eg verapamol, diltiazem
Beta blockers - long acting dihydropyridine CCB eg modified release nifedipine

Question 11

What shoud patients do if develop nitrate tolerance

Answer 11

Second dose of isosorbide mononitrate after 8 hours rather than 12
Allows blood nitrate levels - fall for 4 hours and mainatina effectiveness

Question 12

Complications of angina

Answer 12

Acute coronary syndrome
Myocardial infarction
Unstable angina
Arrhythmias