Ischaemic Heart Disease Flashcards
Define ischaemic heart disease?
Build of disease processes via atherosclerotic plaques Stable angina Unstable angina MI Sudden cardiac death
Describe stable angina?
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.
Which areas of the body can anginal chest pain radiate to?
Jaw
Arms
Teeth
Neck
On examination and history which symptoms and signs may be relevant to a patient with stable angina?
Intermittent claudication Levign sign (fist to the chest)
Name 6 reasons to make a diagnosis of stable angina less likely?
Prolonged chest pain
Not relieved by rest
Brought on by breathing in
Associated with palpitations, tingling, swallowing difficulties
Describe unstable angina?
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
Within the pathophysiology behind unstable angina - what happens when a plaque ruptures?
Ruptured plaque contents = super thrombogenic and therefore form clots around the ruptured plaque
Describe prinzmetal’s angina?
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
Name three drugs that can make prinzmetal’s angina worse?
Aspirin
B-blockers
Cocaine
Which investigations would be suitable for suspected angina?
ECG - often unremarkable FBC - ?anaemia Urine dip - ?DM TFT - ?hyperthyroidism (can make angina worse) CRP - ?arteritis Cholestrol
Which common triggers may set off stable angina?
Cold weather
Exercise
Emotions
Large meals
Name four non modifiable risk factors for IHD?
Male (over 75 = equal)
Ethnicity
Age
FHx
Name six modifiable risk factors associated with IHD?
High BMI Sedentary lifestyle Cholestrol Exercise Diet Smoking
Define typical vs atypical stable angina?
Typical angina = 3/3 1. Sternal chest discomfort 2. Onset with exertion 3. Relieved with rest/GTN (Atypical = 2/3)
Describe the management of stable angina?
Conservative = modifiable risk factor management
Medication = atorvastatin if cholestrol >4.0 or Q-risk = 10%
Aspirin +/- clopidogril
B-blocker
GTN
CCB - nifedipine
What precautions should be taken before starting a statin?
Baseline -
- LFT - as it can be very hepatotoxic
- Createnine kinase - rhabdomyolysis
Define type 1 MI?
Plaque rupture with a thrombus
Define type 2 MI?
Without plaque rupture = myocardial hypoxia
- Vasospasm/endothelial dysfunction (squeezed tube)
- Un-ruptured (fixed) plaque causing occlusion
- Supply/demand imbalance - sepsis/anaemia
In terms of management what is different between type 1 MI vs type 2?
With T2 - don’t require antiplatlet therapies as this may make it worse
Describe a common presentation of an MI?
'Crushing' central chest pain - can radiate to the arms/neck Sweaty and clammy Nausea Vomiting SOB Faint
What five investigations should be undertaken with suspected MI?
ECG - STEMI vs N-STEMI Trop T Createnine kinase MB CXR D-dimer
What is trop T?
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
What is Createnine kinase MB?
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
Pericarditis is a useful DDx for acute chest pain, describe the presentation and clinical findings (5)?
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
Aortic dissection is a useful DDx for acute chest pain, describe the presentation and clinical findings (4)?
Sudden onset chest pain - radiates to back
Very severe - classically tearing pain
Abnormal CXR - widened mediastinum
Differential BP in both arms (R) and (L)
Describe the condition commonly associated with aortic dissection?
Marfan’s syndrome = genetic CT disorder
Can also lead to aortic aneurysms and mitral valve prolapse
GORD is a useful DDx for acute chest pain, describe the presentation and clinical findings (4)?
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
