Ischaemic Heart Disease

Question 1

Lipid Guidelines

Answer 1

No longer a specific target for LDL
High risk 
   = high CVD risk
   = history of IHD
   = >21yrs with high LDL >4.9
   = people with diabetes
High intensity = 40mg rosuvastatin

Question 2

Side effects of statins

Answer 2

Muscle pains
Rhabdomyolysis
LFT derangement
Death
Cognitive impairment
New onset diabetes

Question 3

Anatomical Vs functional study as initial investigation of coronary artery stenosis

Answer 3

Nil significant difference in primary endpoint of death, MI, unstable angina and major complications between Cardiac CT and stress echo/nuclear perfusion/exercise ECG
HOWEVER Cardiac CT reduces the number of normal angiograms done
PROMISE STUDY

Question 4

What is coronary calcification?

Answer 4

Not in normal vessels
Increases with age
Associated with coronary atheroma
Does not correspond with the degree of luminal stenosis

Question 5

What is the coronary calcium score

Answer 5

Agatston score
Non con CT
Detects individuals at risk of cardiovascular events that are not detectable by traditional risk factors
Recommended for those at intermediate risk of CVD - 10-20% 10 yr risk

Question 6

Fractional flow reserve

Answer 6

Ischaemia is defined as FFR <0.8

FAME study = reduces MI and death at 1 yr compared to angiogram guided PCI in multivessel disease

Question 7

Antiplatelet drugs - Ticagrelor Vs Clopidogrel

Answer 7

PLATO study

Ticagrelor has significantly less adverse outcomes and no significant increase in bleeding after 12 months

Question 8

Antiplatelet drugs - Prasugrel Vs Clopidogrel

Answer 8

TRITON study
Prasugrel significantly reduced primary endpoint of death, MI and stroke compared to clopidogrel
Given AFTER coronary anatomy was known

Question 9

Mechanism of action of new antiplatelet agents

Answer 9

T+P act on platelet P2Y12 ADP receptor

Question 10

Differences between prasugrel and ticagrelor?

Answer 10

Prasugrel is a prodrug

Prasugrel binds irreversibly, ticagrelor has reversible binding

Question 11

Mechanism of ticagrelor-mediated dypnoea and ventricular pauses

Answer 11

Adenosine mediated

Question 12

Contraindications for prasugrel?

Answer 12

Prior stroke or TIA, weight < 60kgs, age >75yrs

Question 13

Why clopidogrel is bad?

Answer 13

Prodrug
Must be activated by cytochrome P450
A significant proportion of population are slow metabolism

Question 14

Radial Vs femoral access in ACS

Answer 14

Meta-analysis = radial access –> less bleeding complications –> less death, MI and stroke

Question 15

Role of thrombus aspiration during primary PCI for STEMI?

Answer 15

TOTAL trial

Routine thrombectomy was associated with increased risk of stroke within 30days

Question 16

Fix all disease at STEMI or only culprit lesion?

Answer 16

Current practice = fix only culprit lesion
COURAGE trial = fix only culprit lesion
PRAMI trial = fix all lesions

Question 17

CAGs Vs PCI in 3VD and left main disease

Answer 17

Low risk score = PCI but increased risk of revascularisation
High risk +/- diabetes = CAGs but increased risk of stroke
SYNTAX, FREEDOM and EXCEL studies

Question 18

Medical therapy Vs. PCI for stable angina

Answer 18

PCI did not reduce risk of AMI or death when added to optimal medical therapy
COURAGE trial

Question 19

Stop or continue aspirin pre CAGs

Answer 19

Nil increased risk of death or thrombosis
Nil increased risk of major bleeding
= continue aspirin
ATACAS trial

Question 20

Mechanism of action of proprotein converatase subtilisin/kexin type 9 inhibitors?

Answer 20

Inhibition of LDl receptor degradation

Question 21

What is the GRACE score?

Answer 21

Risk of in hospital mortality after ACS

Age
Heart rate
Systolic BP
Creatinine
ST elevation

> 140 = coronary angiogram within 24hrs

Question 22

What are the different types of MI?

Answer 22

Type 1 = acute plaque rupture with thrombus
Type 2 = vasospasm or endothelial dysfunction
Type 3 = fixed plaque –> decreased supply
Type 4 = Decreased supply only