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MD2 Cardio > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

What disease accounted for the most deaths in Australia according to the 2007-8 National Health Survey?

A

Coronary heart disease (CHD)

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2
Q

Describe the epidemiology of coronary heart disease

A

3% of the Australian population have CHD

Incidence increases with age

Prevalence higher in males

CHD mortality on the decline (has halved between 1987 and 2007, attributed to reduced smoking and improved care)

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3
Q

List the 8 key cardiac risk factors

A

Age

FHx of IHD

Obesity

Sedentary lifestyle

Smoking Hx

Hypercholesterolaemia

HTN

DM

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4
Q

What are 5 common symptoms of IHD?

A

Ischaemic chest pain

SOB

Palpitations

Syncope

Lethargy

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5
Q

Distinguish between stable and unstable angina

A

Stable: comes on with exercise/cold/stress, relieved by rest, no recent change, relieved with GTN

Unstable: new onset pain pain at rest or pain at lower levels of exercise, not relieved by GTN

NB MI is also characterised by pain at rest and is not relieved by GTN

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6
Q

What is the WHO definition of an AMI?

A

At least 2 of the following features:

Symptoms of MI

Elevation of cardiac markers (troponin or CK)

Typical ECG pattern (Q waves, ST segment changes or T wave changes)

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7
Q

Define acute coronary syndrome (ACS)

A

Acute narrowing or occlusion of a coronary artery resulting in ischaemic pain

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8
Q

What is the typical pathophysiology of an ACS?

A

Coronary thrombosis in association with a ruptured atherosclerotic plaque

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9
Q

How might an ACS present clinically?

A

STEMI/NSTEMI

Unstable angina

SCD

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10
Q

64 year old woman with 1/24 typical chest pain, SOB and diaphoresis

Cardiac RFs: HTN, hypercholesterolaemia

Rx: perindopril, atorvastatin

Haemodynamically stable (HR 70 bpm, BP 165/90 mmHg)

O/E unremarkable

What are the key diagnostic features of this ECG?

A

Inferior ST elevation with reciprocal anterolateral ST depression

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11
Q

What is the management of choice for MI in the acute setting? What are the limitations of this management?

A

Reperfusion therapy (PCI or fibrinolysis)

Must be administered within 4 hours of symptom onset for optimal outcome

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12
Q

What options are available for reperfusion therapy?

A

Percutaneous intervention (PCI; generally preferred) Fibrinolysis

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13
Q

When is PCI preferred over fibrinolysis?

A

Skilled lab available

Door to balloon time <60 mins

High-risk patients

CI to fibrinolysis

Late presentation

Dx of STEMI in doubt

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14
Q

When is fibrinolysis preferred over PCI?

A

Early presentation

Invasive strategy not an option

Delay to invasive option

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15
Q

What adjunctive therapies are used in the management of AMI?

A

Oxygen

IV morphine

Aspirin

IV heparin or SC clexane

IV GTN

Additional antiplatelet agents if stent inserted

Evidence for B-blockers and ACEIs post-AMI (MONASH)

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16
Q

What is the significance of a small CK rise on future prognosis?

A

Indicates an improved long-term prognosis with minimal functional impairment of the myocardium (provides an indication of myocardial damage)

17
Q

What is the critical time-dependent goal of reperfusion therapy? What is the time-independent goal?

A

Time-dependent: myocardial salvage (best within 4 hours)

Time-independent: open the infarct-related artery

18
Q

What is the evidence for B-blockers and ACEIs after an AMI?

A

B-blockers reduce morbidity and mortality post-AMI; they reduce angina, arrhythmias and rates of recurrent AMI, and improve LV function

ACEIs may improve LV EF and reduce mortality

19
Q

What discharge medications should a patient be sent home on post-AMI?

A

B blocker

ACEI

Statin

Aspirin

Clopidogrel (9/12; + 3/12 warfarin if high risk)

GTN

20
Q

64 year old male admitted with 8/24 chest discomfort, epigastric pain and SOB

Cardiac RFs: ex-smoker, HTN

PHx: heavy alcohol use

Rx: atenolol

Haemodynamically stable (HR 90 bpm, BP 145/80 mmHg)

O/E: mild LV failure with S3 and bibasal inspiratory creps

What are the key diagnostic features of the presenting ECG?

A

ST depression in leads V5 and V6

T wave changes in leads V2-V4

21
Q

OM1

A

1st obtuse marginal

22
Q

Post-stenting for NSTEMI, patient continued to have persistent SOB but no further chest pain

CK peak: 952 U/L

ECG: resolution of lateral ST depression

Echo: moderate-severe impairment of LV function with lateral wall akinesis, anterior and inferior wall hypokinesis

What are the key features on this CXR? What is the likely clinical course of this patient’s presentation and what does this mean for Mx?

A

Alveolar oedema (“batwings” appearance)

Kerley B lines (interstitial oedema)

Cardiomegaly

Dilated prominent upper lobe vessels

Effusion (pulmonary)

Likely ischaemic insult (NSTEMI) occurred on background of prior LV dysfunction; anti-ischaemic and HF therapy should be optimised

23
Q

Discharge Rx for patient with NSTEMI on background of prior LV dysfunction (i.e. anti-ischaemic and HF therapy)

A

ACEI

B-blocker

Diruetic (e.g. loop diuretic and K+ sparing; may also require slow K)

Thiamine (because of effects of alcohol or diuretic)

Statin

Aspirin

Clopidogrel (9/12 + 3/12 warfarin if high risk)

24
Q

What are the broad categories of possible complications of AMI?

A

Ischaemic

Mechanical

Arrhythmic

Embolic

Inflammatory

(AMI Emergency Indication)

25
Q

What are the possible ischaemic complications of AMI?

A

Angina

Reinfarction

Infarct extension

26
Q

What are the possible mechanical complications of AMI?

A

HF

Cardiogenic shock

Mitral valve dysfunction

Aneurysms

Cardiac rupture

27
Q

What are the possible arrhythmic complications of AMI?

A

Atrial or ventricular arrhythmias

Sinus or AV node dysfunction

28
Q

What are the possible embolic complications of AMI?

A

CNS or peripheral embolisation

29
Q

What are the possible inflammatory complications of AMI?

A

Pericarditis

30
Q

How are the ischaemic complications of AMI treated?

A

Revascularisation (PCI or CABGS)

31
Q

How are the mechanical complications of AMI treated?

A

Consider surgical intervention

32
Q

How are the arrhythmic complications of AMI treated?

A

Anti-arrhythmics

Pacemaker

Implantable defibrillator

33
Q

How are the embolic complications of AMI treated?

A

Consider anticoagulants or antiplatelets

34
Q

How are the inflammatory complications of AMI treated?

A

Anti-inflammatory agents

35
Q

What are the key principles of lifestyle modification post-AMI?

A

Exercise: walk daily for >20 mins

Smoking: cut down or quit

Diet: increase fresh fruit and vegetable intake, reduce fat

Obesity: target weight and waist circumference goals

Alcohol: cut down or quit

Life stressors: identify and reduce if possible

36
Q

What are the key principles of cardiac RF modification post-AMI?

A

DM: management plan (BSL and HbA1c targets, diabetic educator, dietitian, opthalmologist, etc)

Hypercholesterolaemia: aim for total cholesterol less than 4.0 mmol/L and LDL less than 1.8 mmol/L for secondary prevention

HTN: salt restriction and weight reduction

Medications: ensure range of medications used for IHD are instituted and tolerated, ensure role of drug is explained to patient to improve compliance, review medication chart at each review

37
Q

What are the goals of medication management post-AMI?

A

Ensure range of Rx used for IHD are instituted and tolerated

Ensure role of each drug is explained to patient to improve compliance

Review Rx chart at each review

38
Q

Post-hospital management of STEMI

A

1) review at 1/12 then 6/12ly thereafter with cholesterol profile, renal and liver function, CK, FBE, etc 6/12ly
2) repeat echo at 6/12
3) stress testing (nuclear exercise or stress echo) at 12/12
4) regular review of lifestyle changes
5) regular review of Rx chart and compliance

NB Patient care should be INDIVIDUALISED

MD2 Cardio (11 decks)

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