Ischaemic heart disease

Question 1

Risk factors for IHD

Answer 1

MACCAS DO FISH

• Male sex
• Alcohol
• Cholesterol
• Chronic kidney disease
• Age
• Smoking
• Diabetes, diet
• Obesity
• Family history
• Illicit drug use
• Sedentary lifestyle
• Hypertension

+

• Indigenous Australians, South East Asians
• Past history of CHD, peripheral vascular disease OR chronic kidney disease (all equivalent)

Question 2

Characteristics of stable angina

• Brought on by
• Duration
• Quality
• Relieved by

Answer 2

• Brought on by stress and exertion
• • Retrosternal squeezing pain/pressure, may radiate to left arm
• Relieved by rest and GTN

Question 3

Characteristics of unstable angina

• Duration
• Quality
• Progression

Answer 3

• Occurs at rest and lasts >20 minutes
• Is severe and new-onset
• Occurs with a crescendo pattern (becomes much mroe severe, prolonged or frequent)

Question 4

Acute management of unstable angina

Answer 4

MONASH

• Morphine
• Oxygen
• Nitrates
• Aspirin
• Statins
• Heparin

Question 5

Acute management of NSTEMI

Answer 5

• Antiplatelet (aspirin, clopidogrel)
• Anticoagulant (enoxaparin)
• Beta blockers
• PCI/CABG if required

Question 6

Acute management of STEMI

Answer 6

• PCI (stent)
• Fibrinolytics (alteplase)
• Antiplatelets (aspirin, clopidogrel)
• Anticoagulant (enoxaparin)
• CABG

Question 7

Chonic management of unstable angina

Answer 7

SAAB and SNAP

• Statins
• Antiplatelets (aspirin, clopidogrel)
• ACE inhibitors
• Beta blockers
• SNAP (lifestyle intervention)

Question 8

Management of stable angina

Answer 8

• Statins
• ACE inhibitors
• Aspirin
• Beta blockers
• Nitrates (GTN patch, isosorbide mononitrate/dinitrate)
• New anti-anginals (nicorandil, ivabradine)
• PCI/CABG
• SNAP

Question 9

Pathological difference between stable and unstable angina at a vascular level

Answer 9

• Stable angina = thick fibrous cap on top of atherosclerosis
• Unstable angina = thin fibrous cap with lipid core

Question 10

Troponin level (high or low) in:

• Stable angina
• Unstable angina
• NSTEMI
• STEMI

Answer 10

• Low
• Low
• High (after 6 hours)
• High (after 6 hours)

Question 11

Macroscopic pathology of the heart

• Immediately after an AMI
• 5 days after an AMI
• 6-7 weeks after an AMI

Answer 11

• Immediately - no change
• 5 days - well-defined area of necrosis
• 6-7 weeks - full-thickness band of fibrosis

Question 12

Signs of an AMI on ECG (2)

Answer 12

• ST elevation >1mm in a limb lead or >2mm in a chest lead

and/or

• New LBBB

Question 13

Area of heart and ECG leads affected in occlusion of

• Posterior descending artery
• Left anterior descending artery
• Left main coronary artery

Answer 13

• Inferior - II, III and avF
• Anterior - V3 and V4
• Left lateral - V5 and V6

Question 14

Complications of IHD (5)

Answer 14

• Increased risk of future cardiovascular event
• Autoimmune pericarditis (Dresler’s syndrome - glucocytosis, elevated ESR and WCC, pleural effusion, pericarditis 2 weeks after AMI)
• Left ventricular aneurysm, rupture
• Mural thrombus
• Valvular defects