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ESA 2- Cardiovascular System > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

Where are the possible origins of chest pain?

A

Lungs and pleura
GI system; oesophagus, stomach, gall bladder
Chest wall
CVS- heart and great vessels

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2
Q

What can cause chest pain originating from the lungs and pleura?

A

Pneumonia
Pulmonary embolism
Pneumothorax

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3
Q

What can cause chest pain originating from the oesophagus?

A

Reflux

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4
Q

What can cause chest pain originating from the stomach?

A

Peptic ulcer disease

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5
Q

What can cause chest pain originating from the gall bladder?

A

Biliary colic

Cholecystitis

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6
Q

What components of the chest wall can cause chest pain?

A

Ribs
Muscles
Skin

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7
Q

What can cause chest pain originating from the ribs?

A

Fractures

Bone metastases

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8
Q

What aspects of the CVS can cause chest pain?

A

Myocardium
Pericardium
Aorta

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9
Q

What can cause chest pain originating from the myocardium?

A

Angina

MI

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10
Q

What can cause chest pain originating from the pericardium?

A

Pericarditis

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11
Q

What can cause chest pain originating from the aorta?

A

Aortic dissection

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12
Q

What kind of risk factors are there for coronary atheroma?

A

Modifiable and non-modifiable

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13
Q

What are the non-modifiable risks for coronary atheroma?

A

Increasing age
Male gender (females catch up after menopause)
Family history

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14
Q

What are the modifiable risk factors for coronary atheroma?

A 
Hyperlipidaemia 
Smoking
Hypertension 
Diabetes mellitus 
Exercise
Obesity 
Stress
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15
Q

What are the most important risk for coronary atheroma?

A

Hyperlipidaemia
Smoking
Hypertension
Diabetes mellitus

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16
Q

What does coronary atheroma lead to?

A

Ischaemic heart disease

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17
Q

By how much does diabetes mellitus increase the risk of ischaemic heart disease?

A

Doubles it

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18
Q

What is the nature of ischaemic chest pain?

A

Central, retrosternal, or left sided
Pain may radiate to shoulders and arms, with the left side more common than right, along with the neck, jaw, epigastrum and back

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19
Q

Can ischaemia present with pain in other areas, but not the chest?

A

No

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20
Q

How is ischaemic chest pain described as?

A

Tightening, heavy, crushing, constricting and pressure

Occasionally, the pain is described as a burning epigastric pain

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21
Q

When is ischaemic chest pain particularly described as burning epigastric pain?

A

In an inferior MI

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22
Q

How does ischaemic chest pain vary?

A

In intensity, duration, onset, precipitating, aggravating and relieving factors

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23
Q

Do the symptoms associated with ischaemic chest pain vary?

A

Yes

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24
Q

What happens to the symptoms of ischaemic chest pain?

A

They get progressively worse, from stable angina to unstable angina, to MI

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25
Q

When does angina occur?

A

When a plaque occludes more than 70% of the lumen

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26
Q

How does stable angina develop?

A

Atheromatous plaques, with a necrotic centre and fibrous cap, build up in the coronary vessels, leaving less space for the passage of blood. This leads to ischaemia of the myocardium

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27
Q

Describe the chest pain in stable angina

A

Typical ischaemic chest pain in brief episodes, brought on by exertion, emotion, particularly after meals and in cold weather

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28
Q

What is the chest pain in stable angina described as?

A

Mild to moderate pain

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29
Q

How are acute episodes of angina treated?

A

Sub-lingual nitrate spray/tablet

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30
Q

How are episodes of angina prevented?

A

ß-blockers
Ca channel blockers
Oral nitrates

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31
Q

How are cardiac events prevented when a patient has angina?

A

Aspirin
Statins
ACE inhibitors

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32
Q

What are the long term treatments for angina?

A

Consider revascularisation

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33
Q

What causes the worsening of angina?

A

Progression of the formation of the ateromatous plaque

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34
Q

What happens as angina worsens?

A

It progresses from stable to unstable angina

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35
Q

Why does the progression from stable to unstable angina occur?

A

Due to increases occlusion of the lumen

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36
Q

What is unstable angina classified as?

A

Ischaemic chest pain that occurs at rest (or with minimal exertion)

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37
Q

How is unstable angina chest pain described?

A

Severe pain

Occurring with a crescendo pattern

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38
Q

What is meant by a crescendo pattern?

A

Distinctly more severe, prolonged, or frequent than before

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39
Q

What is a myocardial infarction?

A

The complete occlusion of a coronary vessels, leading to an infarct (death) of the myocardium it supplies

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40
Q

What can cause a myocardial infarction?

A

The fibrous cap of the atheromatous plaque can undergo erosion or fissuring, exposing blood to the thombogenic material in the necrotic core. The platelet ‘clot’ is followed by a fibrin thrombus, which can either occlude the entire vessel where it forms, or break off the form an embolism

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41
Q

How does MI present?

A

With typical ischaemic chest pain that is very severe, persistent at rest, and often with no precipitant. It is not relieved by rest or nitrate spray.
Patient may also be breathless, faint, having a ‘feeling of impending death’, an will have autonomic features present

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42
Q

Why may an MI patient feel faint?

A

Due to LV dysfunction

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43
Q

What autonomic features will a MI patient present?

A

Sweating
Pallor
Nausea
Vomiting

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44
Q

What is a NSTEMI?

A

A non ST elevated myocardial infarction

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45
Q

What is a STEMI?

A

A ST elevated myocardial infarction

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46
Q

What is the pathological difference between NSTEMI and STEMI?

A

With a STEMI, the infarct is the full thickness of the myocardium, but with a NSTEMI, it’s not.

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47
Q

What is the clinical diagnosis of angina based on?

A

History

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48
Q

What are the specific signs of angina on examination

A

None

49
Q

What may a patient with angina show signs related to on examination?

A

Risk factors
LV dysfunction
Evidence of atheroma elsewhere

50
Q

What risk factors of atheroma might be present on examination?

A

Elevated BP

Corneal arcus

51
Q

What evidence of atheroma elsewhere could be found?

A

Signs of peripheral vascular disease

52
Q

What will the ECG of someone with angina show?

A

Resting ECG usually normal, but may show signs of previous MI

53
Q

What are the signs of a previous MI on an ECG?

A

Pathological Q wave

54
Q

How is angina confirmed and the severity assessed?

A

An exercise stress test is undertaken

55
Q

What happens in an exercise stress test?

A 
Graded exercise on a treatment connected to an ECG until one of the following happens- 
Target heart rate reached 
Chest pain
ECG changes 
Other problems
56
Q

What other problems may stop an exercise stress test?

A

Arrythmias, low BP etc

57
Q

What is a positive exercise stress test?

A

When the ECG shows ST depressions of >1mm

58
Q

What does a strong positive exercise stress test indicate?

A

Critical stenosis

59
Q

What does acute coronary syndrome (ACS) relate to?

A

A group of symptoms attributed to the obstruction of the coronary arteries

60
Q

What is ACS a result of?

A

Unstable angina
NSTEMI
STEMI

61
Q

What is the priority when diagnosing ACS?

A

Splitting them into two groups, as the treatment is different

62
Q

Is the occlusion by a thrombus in unstable angina?

A

No

63
Q

Is there an occlusion by a thrombus with NSTEMI?

A

Partial

64
Q

Is there occlusion by a thrombus in STEMI?

A

Total

65
Q

Is there myocardial necrosis in unstable angina?

A

No

66
Q

Is there myocardial necrosis in NSTEMI?

A

Some

67
Q

Is there myocardial necrosis in STEMI?

A

Large myocardial infarct

68
Q

What is shown on the ECG with unstable angina?

A

May have ST segment depression, T wave inversion or normal

69
Q

What is shown on the ECG with NSTEMI?

A

No ST segment elevation

70
Q

What is shown on the ECG with STEMI?

A

ST segment elevation in 2 or more leads facing the same area
1mm in limb leads
2mm in chest leads
New left bundle branch block

71
Q

What is the biochemical maker in the blood for unstable angina?

A

None

72
Q

What is the biochemical maker in the blood for NSTEMI?

A

Troponin

73
Q

What is the biochemical marker in the blood for STEMI?

A

Troponin

74
Q

How is an ECG used to differentiate between ACSs?

A

Initial ECG to differentiate STEMI from NSTEMI/unstable angina

75
Q

What happens to the ECG over time in an MI?

A

It undergoes several changes over the course of the MI
In minutes to hours, there will be ST elevation and the T wave will be upright
In hours to half a day, there will be ST elevation, decreased T and R wave, and the Q wave begins
Days 1-2, the Q wave will be deeper
Days later, the ST normalises, T wave is inverted and the Q wave persists
Weeks later, the ST and T are normal, but the Q wave persists

76
Q

How can previous MIs be identified?

A

Via the persistence of the pathological, deepened Q wave

77
Q

How can the site of an MI be localised?

A

Using an ECG

78
Q

Why can an ECG be used to localise the site of an MI?

A

As abnormalities will be seen due to the infarcted, dead myocardium

79
Q

How does an ECG localise the site of an MI?

A

Look at which lead the abnormality is on, and where that leads view is

80
Q

What leads will be affected if there is an inferior infarction in an MI?

A

II, III, aVF

81
Q

What artery is involved in an inferior MI?

A

Right coronary

82
Q

What leads will be affected in an anteroseptal MI?

A

V1-V2

83
Q

What artery is involved in an anteroseptal MI?

A

Left anterior descending

84
Q

What leads will be affected in an anteroapical MI?

A

V3-V4

85
Q

What artery is involved in an anteroapical MI?

A

LAD (distal)

86
Q

What leads will be affected in an anterolateral MI?

A

I, aVL, V5-V6

87
Q

What artery is involved in a anterolateral MI?

A

Circumflex

88
Q

What leads will be affected in an extensive anterior MI?

A

I, aVL, V2-V6

89
Q

What artery is involved in an extensive anterior MI?

A

Proximal LCA

90
Q

What leads will be affected in a true posterior MI?

A

Tall R wave in V1

91
Q

What artery is involved in a true posterior MI?

A

RCA

92
Q

What are the cardiac biomarkers?

A

Troponin

Cardiac enzymes

93
Q

What can cardiac biomarkers be used for?

A

Diagnosis of MI

Distinguishing between NSTEMI and unstable angina

94
Q

What are the cardiac troponins?

A 
Cardiac troponin I (cTnI)
Troponin T (cTnT)
95
Q

What are the cardiac troponins?

A

Proteins important in actin/myosin interactions

96
Q

When are cardiac troponins released?

A

In myocyte death

97
Q

What is the advantage of cardiac tropnins?

A

It is a very sensitive and specific marker for MI

98
Q

Describe what happens to cardiac troponin levels after an MI?

A

It rises 3-4 hours after the first onset on pain
Peaks at 18-36 hours
Will then decline slowly for up to 10-14 days

99
Q

How many iso-enzymes of creatine kinase (CK) are there?

A

3

100
Q

Where are the isoenzymes of CK found?

A

Heart, muscle, brain

101
Q

What is the cardiac isoenzyme of CK?

A

CK-MB

102
Q

Describe what happens to CK-MB levels after a MI?

A

It rises 3-8 hours after onset
Peaks at 24 hours
Levels return to normal in 48-72hrs

103
Q

How can CK-MB and cardiac troponins be used to distinguish between unstable angina and NSTEMI?

A

The presence of either of these enzymes means that there has been death of the myocardium, which only happens in NSTEMI, as there is no tissue death in unstable angina

104
Q

What is the goal in unstable angina treatment?

A

Prevent it from progressing to MI and limiting muscle loss in MI

105
Q

How is the progression of unstable angina to thrombosis prevented?

A

Antithrombotic therapy

106
Q

What is given in antithrombotic therapy?

A

Anti-platelet agents

Anticoagulants

107
Q

Give an example of an anti-platelet agent

A

Aspirin

108
Q

Give an example of an anticoagulant

A

Hepatin

109
Q

How is perfusion restored in partially occluded vessels when there is a high risk of MI?

A

Early percutaneous coronary intervation (angioplasty)

Coronary artery bypass graft

110
Q

What is perfusion restored in partially occluded vessels when there is a low risk of MI?

A

Initally medical treatment

111
Q

What is the general treatment used to restore perfusion of partially occluded vessels/

A 
Pain control 
Oxygen 
Organic nitrates 
ß-blockers 
Statins 
ACE-inhibitors
112
Q

What are the surgical treatments in coronary artery disease?

A

Angiography
Percutaenous coronary artery intervention (PCI)
Coronary bypass grafting (CGPG)

113
Q

What can angiography be used to do?

A

View any vessel occlusions, and from the findings choices can be made about the revascularisation surgeries

114
Q

What does PCI involve?

A

Angioplasty and stenting

115
Q

What happens in stenting?

A

Inflation of a ballon inside the occluded vessel expands a mesh that holds the vessel open, increasing the lumen size and allowing for more blood flow

116
Q

What does CBPG involve?

A

Taking an artery from elsewhere in the body and grafting it to the heart

117
Q

What vessels might be used for CBPG?

A

Internal mammary artery
Radial artery
Saphenous vein (reversed because of valves)

118
Q

What are the causes of acute pericarditis?

A 
Infections (viral, TB) 
Post MI/ cardiac surgery 
Autoimmune 
Uraemia (kidney failure) 
Malignant deposits
119
Q

What are the symptoms of acute pericarditis?

A

Central/left sided chest pain
Sharp, worse on inspiration
Improved by leading forward

ESA 2- Cardiovascular System (18 decks)

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