Ischaemic Heart Disease

Question 1

Define ischaemic heart disease?

Answer 1

Build of disease processes via atherosclerotic plaques
Stable angina
Unstable angina
MI
Sudden cardiac death

Question 2

Describe stable angina?

Answer 2

Patient is okay at rest however develops chest pain with activity = central strangling feeling, precipitated by various triggers. With rest or removal of triggers the symptoms resolve. Other symptoms include sweat, nausea, SOB, faintness.

Question 3

Which areas of the body can anginal chest pain radiate to?

Answer 3

Jaw
Arms
Teeth
Neck

Question 4

On examination and history which symptoms and signs may be relevant to a patient with stable angina?

Answer 4

Intermittent claudication
Levign sign (fist to the chest)

Question 5

Name 6 reasons to make a diagnosis of stable angina less likely?

Answer 5

Prolonged chest pain
Not relieved by rest
Brought on by breathing in
Associated with palpitations, tingling, swallowing difficulties

Question 6

Describe unstable angina?

Answer 6

Angina with increased frequency and severity which occurs at rest or with minimal exertion. Typically involves a flappy plaque which intermittently occludes the coronary (A). No response to GTN

Question 7

Within the pathophysiology behind unstable angina - what happens when a plaque ruptures?

Answer 7

Ruptured plaque contents = super thrombogenic and therefore form clots around the ruptured plaque

Question 8

Describe prinzmetal’s angina?

Answer 8

Angina due to coronary (A) spasm - often occurring with a fixed aortic stenosis.
Chest pain occurs at rest.
ECG findings may show a STEMI however this resolves with the symptoms.
Patients often do NOT have standard R/F for atherosclerosis

Question 9

Name three drugs that can make prinzmetal’s angina worse?

Answer 9

Aspirin
B-blockers
Cocaine

Question 10

Which investigations would be suitable for suspected angina?

Answer 10

ECG - often unremarkable
FBC - ?anaemia
Urine dip - ?DM
TFT - ?hyperthyroidism (can make angina worse)
CRP - ?arteritis 
Cholestrol

Question 11

Which common triggers may set off stable angina?

Answer 11

Cold weather
Exercise
Emotions
Large meals

Question 12

Name four non modifiable risk factors for IHD?

Answer 12

Male (over 75 = equal)
Ethnicity
Age
FHx

Question 13

Name six modifiable risk factors associated with IHD?

Answer 13

High BMI
Sedentary lifestyle
Cholestrol
Exercise
Diet
Smoking

Question 14

Define typical vs atypical stable angina?

Answer 14

Typical angina = 3/3
1. Sternal chest discomfort
2. Onset with exertion 
3. Relieved with rest/GTN
(Atypical = 2/3)

Question 15

Describe the management of stable angina?

Answer 15

Conservative = modifiable risk factor management
Medication = atorvastatin if cholestrol >4.0 or Q-risk = 10%
Aspirin +/- clopidogril
B-blocker
GTN
CCB - nifedipine

Question 16

What precautions should be taken before starting a statin?

Answer 16

Baseline -

1. LFT - as it can be very hepatotoxic
2. Createnine kinase - rhabdomyolysis

Question 17

Define type 1 MI?

Answer 17

Plaque rupture with a thrombus

Question 18

Define type 2 MI?

Answer 18

Without plaque rupture = myocardial hypoxia

1. Vasospasm/endothelial dysfunction (squeezed tube)
2. Un-ruptured (fixed) plaque causing occlusion
3. Supply/demand imbalance - sepsis/anaemia

Question 19

In terms of management what is different between type 1 MI vs type 2?

Answer 19

With T2 - don’t require antiplatlet therapies as this may make it worse

Question 20

Describe a common presentation of an MI?

Answer 20

'Crushing' central chest pain - can radiate to the arms/neck
Sweaty and clammy
Nausea
Vomiting
SOB
Faint

Question 21

What five investigations should be undertaken with suspected MI?

Answer 21

ECG - STEMI vs N-STEMI
Trop T
Createnine kinase MB
CXR
D-dimer

Question 22

What is trop T?

Answer 22

Troponin T = very specific cardiac marker, rises 4-8 hours following an injury peaks at 24/48 hours. Remains elevated for up to 2 weeks. Used for prognostic basis
Can be chronically raised with CDK, poly/dermyositis so paired testing is important

Question 23

What is Createnine kinase MB?

Answer 23

Cardiac marker which rises 4-8 hours and peaks at 34. Remains elevated for up to 48 hours
Positive if CK/MB ratio >5%
False positives with exercise, trauma, muscle disease, DM and PE

Question 24

Pericarditis is a useful DDx for acute chest pain, describe the presentation and clinical findings (5)?

Answer 24

Central chest pain - better sitting/leaning forward
Worse on inspiration
Sharp and jaggy pain
Associated with rub on auscultation
ECG changes = ST elevation across all leads

Question 25

Aortic dissection is a useful DDx for acute chest pain, describe the presentation and clinical findings (4)?

Answer 25

Sudden onset chest pain - radiates to back
Very severe - classically tearing pain
Abnormal CXR - widened mediastinum
Differential BP in both arms (R) and (L)

Question 26

Describe the condition commonly associated with aortic dissection?

Answer 26

Marfan’s syndrome = genetic CT disorder

Can also lead to aortic aneurysms and mitral valve prolapse

Question 27

GORD is a useful DDx for acute chest pain, describe the presentation and clinical findings (4)?

Answer 27

Pain often worse lying down
Associated with acid reflux in the mouth (acid brush)
Relieved by antacids and sleeping propped and GTN
Affected by food