Ischaemic Heart Disease

Question 1

In whom is there a higher prevalence of coronary heart disease: males or females?

Answer 1

Males, in all age groups

Question 2

What has the decrease in the death rate due to coronary heart disease been partly attributed to?

Answer 2

Reduced smoking

Improved medical care

Question 3

What are the key cardiac risk factors?

Answer 3

Increasing age
Family history of ischaemic heart disease
Obesity
Sedentary lifestyle
Smoking
Hypercholesterolaemia
Hypertension
Diabetes
Chronic kidney disease

Question 4

What are the presenting symptoms of ischaemic heart disease?

Answer 4

Ischaemic chest pain
Shortness of breath
Palpitations
Syncope
Lethargy

Question 5

How is ischaemic chest pain often described?

Answer 5

Pressure
Discomfort
Ache
Tightness in chest
\+/- arm pain
May be mistaken for indigestion

Question 6

Describe chest pain in stable angina

Answer 6

Pain comes on with
- Exercise
- Cold
- Stress
Relieved by rest
No recent change

Question 7

Describe chest pain in unstable angina

Answer 7

New onset pain/pain at rest

Pain at lower levels of exercise

Question 8

Describe chest pain in myocardial infarction

Answer 8

Pain at rest

Question 9

How does the cause of atypical pain change with age?

Answer 9

If you’re young, atypical pain less likely to be heart disease
If you’re older, atypical pain more likely to be heart disease

Question 10

What is an acute myocardial infarction?

Answer 10

At least 2 of

• Symptoms of myocardial ischaemia
• Elevation of cardiac markers
  
  • Troponin
  • Creatine kinase
• Typical ECG pattern
  
  • Q waves
  • ST segment changes
  • T wave changes

Question 11

What is an acute coronary syndrome?

Answer 11

Usually caused by coronary thrombosis in association with ruptured atherosclerotic plaque
Causes acute narrowing/occlusion of coronary artery
- Pain due to acute decrease in myocardial oxygen supply

Question 12

How does acute coronary syndrome typically present?

Answer 12

ST elevation myocardial infarction
Non-ST elevation myocardial infarction
Unstable angina
Sudden cardiac death

Question 13

What is the optimal time for reperfusion therapy?

Answer 13

Less than 4 hours

Question 14

What is the preferred reperfusion strategy, generally?

Answer 14

Primary percutaneous intervention (PCI) preferred over fibrinolysis

Question 15

When is primary PCI preferred over fibrinolysis?

Answer 15

Skilled lab
Door to balloon time <60 mins
High-risk patients
Contraindications for fibrinolysis
Late presentation
Diagnosis of ST elevation myocardial infarction in doubt

Question 16

When is fibrinolysis preferred over primary PCI?

Answer 16

Early presentation
Invasive strategy not an option
Delay to invasive option

Question 17

What are the adjunctive therapies in acute myocardial infarction?

Answer 17

Oxygen
IV morphine
Aspirin
IV heparin/subcutaneous clexane
IV GTN
Extra antiplatelet agents if stent inserted

Question 18

What is the evidence for beta blockers after an acute myocardial infarction?

Answer 18

Reduce morbidity and mortality
Effects include
- Reducing rates of recurrent myocardial infarction
- Reducing angina
- Reducing arrhythmias
- Improving left ventricular function

Question 19

What is the evidence for ACE inhibitors after an acute myocardial infarction?

Answer 19

Improves left ventricular ejection fraction

Reduces mortality

Question 20

What is the significance of a small creatine kinase rise on future progress?

Answer 20

Didn’t have much cardiac muscle damage

- Good prognosis, especially in terms of cardiac failure

Question 21

What are the ischaemic complications of acute myocardial infarction?

Answer 21

Angina
Re-infarction
Infarct extension

Question 22

What are the mechanical complications of acute myocardial infarction?

Answer 22

Heart failure
Cardiogenic shock
Mitral valve dysfunction
Aneurysms
Cardiac rupture

Question 23

What are the arrhythmic complications of acute myocardial infarction?

Answer 23

Atria/ventricular arrhythmias

Sinus/AV node dysfunction

Question 24

What are the embolic complications of acute myocardial infarction?

Answer 24

CNS/peripheral embolisation

Question 25

What are the inflammatory complications of acute myocardial infarction?

Answer 25

Pericarditis

Question 26

How do we treat ischaemic complications of acute myocardial infarction?

Answer 26

Revascularisation

• PCI
• Coronary artery bypass graft (CABG)

Question 27

How do we treat mechanical complications of acute myocardial infarction?

Answer 27

Consider surgical intervention

Question 28

How do we treat arrhythmic complications of acute myocardial infarction?

Answer 28

Anti-arrhythmics
Pacemaker
Implantable defibrillator

Question 29

How do we treat embolic complications of acute myocardial infarction?

Answer 29

Consider

• Anticoagulants
• Antiplatelet drugs

Question 30

How do we treat inflammatory complications of acute myocardial infarction?

Answer 30

Anti-inflammatory agents

Question 31

What are the goals of post-hospital management of an acute myocardial infarction?

Answer 31

Modify lifestyle
Modify cardiac risk factors
Medications

Question 32

How is lifestyle modified?

Answer 32

No regular exercise: aim to walk daily for >20 mins
Smoking: aim to cut down/out smoking
Unhealthy diet: im to eat fresh fruit and vegetables
Overweight: target weight +/- waist circumference goals
Alcohol excess: cut down/out alcohol
Stress: identify life stressors, and reduce, if possible

Question 33

How are cardiac risk factors modified?

Answer 33

Diabetes: management plan
Hypercholesterolaemia
- Aim for total cholesterol <4.0 mmol/L
- Aim for LDL <1.8 mmol/L
Hypertension
- Salt restriction
- Weight reduction

Question 34

How are medications managed after an acute myocardial infarction?

Answer 34

Ensure medications used instituted and tolerated
Explain role of each drug to patient > improves compliance
Review medication chart at each review