Ischaemic Heart Disease Flashcards
Define IHD
decreased blood supply to heart muscle resulting in chest pain (angina pectoris).
May present as stable angina or acute coronary syndrome.
How can ACS be subdivided?
Unstable angina: rest pain due to ischaemia, without cardiac injury
NSTEMI: ST depression, subendocardial injury
STEMI: ST elevation with transmural infarction
Define Myocardial Infarction
cardiac muscle necrosis resulting from ischaemia
Describe the epidemiology of ischaemic heart disease
COMMON
5/1000 PA
Prevalence: > 2 %
M > F
Describe the aetiology of Angina Pectoris
Myocardial O2 demand exceeds supply
Often due to atherosclerosis
Rarer causes: coronary artery spasm (e.g. cocaine), arteritis + emboli
List 9 risk factors for IHD
Male Age FHx Diabetes mellitus HTN Hyperlipidaemia Smoking Diet + exercise Alcohol
Describe the pain that characterise ACS
Acute-onset chest pain
Central, heavy, tight, crushing
Radiates to the arms, neck, jaw or epigastrium
Occurs at rest
More severe + frequent pain than previously occurring stable angina
What are 3 associated symptoms of ACS?
Breathlessness
Sweating
Nausea + vomiting
What may occur in elderly or diabetic patients with ACS?
Silent infarcts
Describe the presenting symptoms of stable angina
Constricting discomfort in the chest, neck, shoulders, jaw + arms on exertion
Relieved by GTN/ rest within 5 minutes
What are 8 signs of ACS?
May be NO CLINICAL SIGNS Pale Sweating Restless Low-grade pyrexia Check both radial pulses to rule out aortic dissection Arrhythmias/ New heart murmurs Disturbances of BP Signs of complications (e.g. acute HF, cardiogenic shock)
What are the appropriate bloods to take for suspected ACS?
FBC U+E's (electrolyte imbalance) Glucose Lipid profile Amylase (pancreatitis could mimic MI) CRP TFT's
Which cardiac enzymes rise in ACS and when?
CK-MB (within 6 hours)
Troponin I + T (3-6 hours after infarction, peak at 12-24 hours, remain raised for up to 14 days)
Describe ECG findings for unstable angina and NSTEMI
ST depression or T wave inversion
Describe ECG findings for STEMI
Hyperacute tall T waves
ST elevation (> 1 mm in limb leads, > 2 mm in chest leads)
New-onset LBBB
Later: T wave inversion, Pathological Q waves
What may a CXR in ACS show?
Complications of ischaemia eg, pulmonary oedema
Cardiomegaly
Enlarged mediastinum
What is the medical management strategy of stable angina?
Symptomatic (GTN)
Anti-anginals (BBs/CCBs)
Risk factor reduction (statins, aspirin, ACEi)
Describe the conservative management of stable angina
Stop smoking
Lose weight
Exercise
How do you treat patients with stable angina when pharmaceutical methods are ineffective?
Percutaneous coronary intervention
Coronary Artery Bypass Graft
Describe the acute management of ACS
MONABASH Morphine 2.5-5mg IV Oxygen Nitrates Antiplatelets (300mg Aspirin + 300mg Clopidogrel) Beta-blockers ACE inhibitors Statins Heparin 5000 units
Detail the treatment of unstable Angina and NSTEMI
Immediate
300mg Aspirin + other anti-platelets (e.g. clopidogrel, Ticagrelor)
Either:
· Fondaparinux (NOAC): if low bleeding risk + no coronary angiography planned in <24hrs
· LMWH: if coronary angiogram planned
Risk stratification – GRACE score:
High risk: Glp2b/3a inhibitors + coronary angiography (<72hrs)
Low risk: conservative RF control
Detail the treatment of STEMI depending on time since onset of symptoms
<12 hours: PCI (if <120 mins), thrombolysis if >120 minutes + rescue PCI
>12 hours: coronary angiography + PCI if indicated
What medical therapy is used to address STEMI?
GP IIb/IIIa receptor antagonist e.g. Abciximab (pre-catheterisation)
Anticoagulant e.g. Heparin until PCI/ 48hrs post fibrinolytic
Dual anti platelet therapy: Aspirin + clopidogrel (or ticagrelor) for >,12 months
What are the complications of ACS?
DARTH VADER Death Arrhythmias Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's Syndrome Embolism Re-infarction
