Ischaemic Heart Disease

Question 1

What is ischaemic heart disease?

Answer 1

Characterised by decreased blood supply to the heart muscle resulting in chest pain (angina pectoris). May present as stable angina or acute coronary syndrome. 

Question 2

What are the risk factors for ischaemic heart disease?

Answer 2

• Male  
• Diabetes mellitus  
• Family history  
• Hypertension  
• Hyperlipidaemia  
• Smoking 

Question 3

What are the presenting symptoms of ischaemic heart disease?

Answer 3

1. ACS 
   - Acute-onset chest pain 
   - Central, heavy, tight, crushing pain  
   -Radiates to the arms, neck, jaw or epigastrium  
   - Occurs at rest  
   - More severe and frequent pain that previously occurring stable angina  
   - Associated symptoms: 
   *Breathlessness  
   *Sweating  
   *Nausea and vomiting  
   - SILENT INFARCTS occur in the elderly and diabetics  
   - Stable Angina: Chest pain brought on by exertion and relieved by rest  

Question 4

What investigations are used to diagnose/ monitor ishchaemic heart disease?

Answer 4

1. Contrast-Enhanced CT Coronary Angiogram (1st line imaging for stable angina) → visualise coronary arteries and determine feasibility of intervention using PCI
2. Cardiac Stress Testing (ECG whilst exercising)
3. ECG → best initial test for chest pain. Pathologic Q waves (negative deflection preceding an R wave) indicate prior infarct.
   - Then do troponin after ECG

Question 5

How is ischaemic heart disease managed?

Answer 5

1. Stable Angina
   - All patients should be on an antiplatelet (aspirin or clopidogrel) and statin
   - GTN Spray → to abort angina attacks
   *Side Effects ⇒ headaches, flushing, dizziness
2. 1st Line → Beta-Blocker (bisoprolol/atenolol) or CCB (verapamil/diltiazem)
   - If together, use Nifedipine/Amlodipine (non-cardioselective) as CCB (verapamil/diltiazem can’t be used alongside beta blocker → causes severe bradycardia and heart block)
   - BB’s C/I in asthma
3. Overall ⇒ beta-blocker (or CCB) + GTN + aspirin 75mg + statin 20mg
4. If symptoms not controlled medically, may have Percutaneous coronary intervention (PCI) or CABG (coronary artery bypass graft)

Question 6

What complications may arise from ishcaemic heart disease?

Answer 6

• Death 
• Arrhythmias 
• Rupture 
• Tamponade 
• Heart failure 
• Valve disease  
• Aneurysm 
• Dressler’s syndrome 
• Embolism 

Question 7

Describe the prognosis of ischaemic heart disease?

Answer 7

TIMI score (0-7) can be used for risk stratification  

NOTE: TIMI = thrombolysis in myocardial infarction 

High scores are associated with high risk of cardiac events within 30 days of MI 

Question 8

What classification is used to monitor is ishcaemic heart disease?

Answer 8

Killip Classification of acute MI can also be used: 
- Class I: no evidence of heart failure 
- Class II: mild to moderate heart failure 
- Class III: over pulmonary oedema  
- Class IV: cardiogenic shock