Ischaemic Heart Disease Flashcards
What’s the difference between stable and unstable angina?
Stable angina - physical exertion or emotional stress, relieved within minutes of rest or GTN
Unstable- new onset angina or abrupt deterioration of stable angina, occurring at rest. Requires hospital admission
What is some lifestyle advice given to patients to manage stable angina?
Smoking cessation
Cardioprotective diet
Achieve and maintain healthy weight
Increase physical activity
Limit alcohol consumption
What drugs are used to treat angina?
Sublingual glyceryl trinitrate - rapid symptom relief
Beta blocker or CCB
2nd line - long acting nitrate (isosorbide mononitrate), Ivabradine, Nicorandil, Ranolazine
What drugs can be given to angina patients for secondary prevention of cardiovascular events?
Antiplatelet treatment - 75mg aspirin
ACEi for people with: coexisting hypertension, heart failure, asymptomatic left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction
HTN and hyperlipidemia treatment if required
When should an angina patient be admitted to hospital?
Pain at rest (which may occur at night).
Pain on minimal exertion.
Angina that seems to be progressing rapidly despite increasing medical treatment
What are some risk factors of angina?
stress
smoking
diabetes
obesity
high cholesterol
high blood pressure
family history of heart disease
older age (45+ for men and 55+ for women).
How is angina diagnosed?
ECG - Pathological Q waves (in particular).
Left bundle branch block (LBBB).
ST-segment and T-wave abnormalities
Exercise stress test
Coronary angiography
Whats the “typical” angina presentation?
-all three of the following features:
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
How does “Atypical” angina present
-two of the following features:
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
AND atypical symptoms include gastrointestinal discomfort, and/or breathlessness, and/or nausea
What are factors that would make a stable angina diagnosis less likely?
Pain that is continuous or prolonged.
Pain that is unrelated to activity.
Pain that is brought on by breathing.
Pain that is associated with dizziness, palpitations, tingling, or difficulty swallowing
What is Acute coronary syndromes (ACS)?
a spectrum of conditions which include myocardial infarction with or without ST-segment-elevation (STEMI or NSTEMI respectively), and unstable angina
Result from the formation of a thrombus on an atheromatous plaque in a coronary artery
How is a definitive diagnosis of ACS made?
Clinical presentation
ECG changes
Measurement of biochemical cardiac markers
What is a STEMI?
generally caused by a complete and persistent blockage of the artery resulting in myocardial necrosis with ST-segment elevation seen on the ECG
What non-drug treatments are available for ACS?
PCI or coronary artery bypass graft (CABG) alongside drug treatments
Decision depends on: type of ACS, time since symptom onset, the patient’s clinical condition, comorbidities, and their formally-assessed risk of future cardiovascular events
What’s the initial management for a patient presenting with ACS?
Pain relief - GTN or IV opioids
Loading dose aspirin 300mg
Oxygen if required
Monitor for hyperglycaemias - if higher than 11mmol/L - receive insulin
What is the management of a stemi?
restore adequate coronary blood flow as quickly as possible:
-Coronary reperfusion therapy (either primary PCI or fibrinolysis)
-Aspirin 300mg and 2nd antiplatelet agent (prasugrel, ticagrelor, or clopidogrel)
-For patients undergoing primary PCI with radial access, heparin (unfractionated) should also be given
-For patients undergoing fibrinolysis, an antithrombin agent should be given at the same time
What occurs in NSTEMI and unstable angina?
partial or intermittent blockage of the artery occurs, which usually results in myocardial necrosis in NSTEMI but not in unstable angina
What may ECG show in NSTEMI and unstable angina?
ST-segment depression, T-wave inversion, or may be normal
How can you differentiate between NSTEMI and unstable angina?
High-sensitivity blood tests for serum troponin
Higher in NSTEMI
How is unstable angina and NSTEMI managed?
Reperfusion therapy or medical management
Aspirin 300mg plus second antiplatelet agent (prasugrel, ticagrelor, or clopidogrel)
Antithrombin therapy with fondaparinux sodium UNLESS undergoing immediate coronary angiography
Heparin (unfractionated) may be used as an alternative in patients with significant renal impairment
Patients undergoing PCI should be offered heparin (unfractionated) in the cardiac catheter laboratory
What should all patients be offered following an ACS?
cardiac rehabilitation programme:
-advice for lifestyle changes, stress management and health education
-include healthy eating, reducing alcohol consumption, regular physical exercise, smoking cessation and weight management
Secondary prevention treatment:
-angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, dual antiplatelet therapy and statin
What are symptoms on an ACS?
Chest pain or discomfort. This is often described as aching, pressure, tightness or burning. Chest pain also is called angina.
Pain that starts in the chest and spreads to other parts of the body. These areas include the shoulders, arms, upper belly area, back, neck or jaw.
Nausea or vomiting.
Indigestion.
Shortness of breath, also called dyspnea.
Sudden, heavy sweating.
Racing heartbeat.
Feeling lightheaded or dizzy.
Fainting.
Unusual fatigue.
What are some risk factors for an ACS?
Smoking
High blood pressure
High blood cholesterol
Diabetes
Physical inactivity
Being overweight or obese
A family history of chest pain, heart disease or stroke
How is AF detected?
person is symptomatic or detected incidentally if a person has an irregular pulse on examination or irregular heart rhythm on an electrocardiogram (ECG)
When should AF be suspected?
Has irregular pulse
Breathlessness and/or reduced exercise tolerance
Palpitations
Dizziness or syncope
Fatigue, tiredness, sleep disturbances
person presents with a self-initiated mobile or wearable device-provided irregular pulse notifications or ECG tracings
How is AF confirmed?
On 12 lead ECG:
confirmed if the heart rhythm shows an absence of distinct repeating P waves, irregular atrial activations, irregularly irregular R-R intervals, and a narrow QRS complex
What are some complications of AF?
Stroke
Heart failure
exacerbate symptoms of myocardial ischaemia
may cause tachycardia-induced cardiomyopathy and ventricular dysfunction
increased risk of cognitive impairment and vascular dementia
How should you examine suspected AF patient?
Palpate the radial pulse and auscultate the heart at the apex to check pulse rate and regularity
Check BP manually
Assess for signs of haemodynamic instability, such as tachycardia, hypotension, severe dizziness, syncope, chest pain
Auscultate the heart for a murmur that may suggest other pathology
Examine the lungs to assess for pulmonary oedema and/or an underlying cause
Check for other signs of heart failure such as ankle or leg oedema
What are some risk factors for AF?
Cardiac or valve conditions
Acute illness e.g. pneumonia
COPD
CKD
Electrolyte imbalance
Thyrotoxicosis
Increasing age
Alc excess
Obesity
Smoking
Medications such as thyroxine, lithium, or beta-2 agonist bronchodilators
What is the CHA2DS2-VASc score?
used to assess a person’s stroke risk:
Congestive heart failure/left ventricular dysfunction (heart failure with reduced ejection fraction or people with recent decompensated heart failure requiring hospitalization, irrespective of ejection fraction) = 1
Hypertension (defined as a resting blood pressure greater than 140 mmHg systolic and/or greater than 90 mmHg diastolic on at least 2 occasions or current
antihypertensive drug treatment) = 1
Age older than or equal to 75 years = 2
Diabetes mellitus (defined as fasting plasma glucose level of 7.0 mmol/L [126 mg/dL] or more, or treatment with oral hypoglycaemic drugs and/or insulin) = 1
Stroke/transient ischaemic attack = 2
Vascular disease (prior myocardial infarction, peripheral arterial disease, or aortic plaque) = 1
Age 65–74 years = 1
Sex category (female) = 1
What is the ORBIT bleeding risk score?
identify people at high risk of bleeding to help guide decisions on anticoagulation treatment and monitoring
Scores range from 0 to 7:
There is a score of 2 points for:
-Males with haemoglobin less than 130 g/L or haematocrit less than 40%.
-Females with haemoglobin less than 120 g/L or haematocrit less than 36%.
-People with a history of bleeding (for example, gastrointestinal or intracranial bleeding or haemorrhagic stroke).
There is a score of 1 point for people:
-Aged over 74 years.
-Who have an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2.
-Treated with antiplatelet drugs.
How should ORBIT score be interpreted?
0-2 low risk
3 medium risk
4-7 high risk
How should drug treatment for AF be monitored?
Anticoags:
-If a person is taking a direct-acting oral anticoagulant (DOAC), assess adherence to treatment and ask about any adverse effects
-If a person is taking a vitamin K antagonist such as warfarin, ensure anticoagulation control is reviewed regularly - INR
Rate control:
-Arrange to review the person within one week of starting rate-control treatment or each dose titration, to assess symptom control, resting heart rate, blood pressure, adherence to treatment, and any adverse effects
What drug treatment should be offered for AF patients?
DOAC if CHA2DS2VASc score 2 or higher (or 1 in men)
If a DOAC is contraindicated, not tolerated, or not suitable, offer treatment with a vitamin K antagonist such as warfarin
Rate control if reversible cause not found:
standard beta-blocker (other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem [off-label indication] or verapamil) first-line
How should acute presentations of AF be managed?
with life-threatening haemodynamic instability caused by new-onset atrial fibrillation should undergo emergency electrical cardioversion
without life-threatening haemodynamic instability, rate or rhythm control can be offered if the onset of arrhythmia is less than 48 hours
What is heart failure with preserved ejection fraction (HFpEF)?
Heart pumps normally but too stiff to fill properly
LVEF >50%
What is heart failure with reduced ejection fraction?
Left ventricle pumps out less blood than normal - weak muscles
LVEF <40%
How is heart failure diagnosed?
-Detailed history and examination
-Measure NT-proBNP
-if 400 ng/l or higher refer for ECHO
How can chronic heart failure symptoms be managed?
Diuretics for congestive symptoms and fluid retention
How is HEpEF managed?
1) manage comorbidities
2) offer personalised exercise-based cardiac rehab programme unless unstable
3) loop diuretic for relief of fluid retention
When should drug treatment for heart failure be monitored?
serum potassium and sodium, renal function, and blood pressure should be checked prior to starting treatment, 1-2 weeks after starting treatment, and at each dose increment
treatment should be monitored monthly for 3 months and then at least every 6 months, and if the patient becomes acutely unwell.
How should HFrEF be managed?
1) offer ACEi or beta-blocker. Add MRA if symptoms continue
2) Offer a personalised exercise-
based cardiac rehabilitation
programme
3) If symptoms persist despite first-line treatment,seek specialist advice, consider adding one of:
-Replace ACEI (or ARB) with sacubitril valsartan* if ejection fraction <35%
- Add ivabradine for sinus rhythm with HR >75bpm and ejection fraction <35%
-Add hydralazine and nitrate (esp if Afro-caribbean)
-Digoxin for symptoms
