Ischaemic Heart Disease Flashcards
In whom is there a higher prevalence of coronary heart disease: males or females?
Males, in all age groups
What has the decrease in the death rate due to coronary heart disease been partly attributed to?
Reduced smoking
Improved medical care
What are the key cardiac risk factors?
Increasing age Family history of ischaemic heart disease Obesity Sedentary lifestyle Smoking Hypercholesterolaemia Hypertension Diabetes Chronic kidney disease
What are the presenting symptoms of ischaemic heart disease?
Ischaemic chest pain Shortness of breath Palpitations Syncope Lethargy
How is ischaemic chest pain often described?
Pressure Discomfort Ache Tightness in chest \+/- arm pain May be mistaken for indigestion
Describe chest pain in stable angina
Pain comes on with - Exercise - Cold - Stress Relieved by rest No recent change
Describe chest pain in unstable angina
New onset pain/pain at rest
Pain at lower levels of exercise
Describe chest pain in myocardial infarction
Pain at rest
How does the cause of atypical pain change with age?
If you’re young, atypical pain less likely to be heart disease
If you’re older, atypical pain more likely to be heart disease
What is an acute myocardial infarction?
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
What is an acute coronary syndrome?
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
How does acute coronary syndrome typically present?
ST elevation myocardial infarction
Non-ST elevation myocardial infarction
Unstable angina
Sudden cardiac death
What is the optimal time for reperfusion therapy?
Less than 4 hours
What is the preferred reperfusion strategy, generally?
Primary percutaneous intervention (PCI) preferred over fibrinolysis
When is primary PCI preferred over fibrinolysis?
Skilled lab Door to balloon time <60 mins High-risk patients Contraindications for fibrinolysis Late presentation Diagnosis of ST elevation myocardial infarction in doubt
When is fibrinolysis preferred over primary PCI?
Early presentation
Invasive strategy not an option
Delay to invasive option
What are the adjunctive therapies in acute myocardial infarction?
Oxygen IV morphine Aspirin IV heparin/subcutaneous clexane IV GTN Extra antiplatelet agents if stent inserted
What is the evidence for beta blockers after an acute myocardial infarction?
Reduce morbidity and mortality Effects include - Reducing rates of recurrent myocardial infarction - Reducing angina - Reducing arrhythmias - Improving left ventricular function
What is the evidence for ACE inhibitors after an acute myocardial infarction?
Improves left ventricular ejection fraction
Reduces mortality
What is the significance of a small creatine kinase rise on future progress?
Didn’t have much cardiac muscle damage
- Good prognosis, especially in terms of cardiac failure
What are the ischaemic complications of acute myocardial infarction?
Angina
Re-infarction
Infarct extension
What are the mechanical complications of acute myocardial infarction?
Heart failure Cardiogenic shock Mitral valve dysfunction Aneurysms Cardiac rupture
What are the arrhythmic complications of acute myocardial infarction?
Atria/ventricular arrhythmias
Sinus/AV node dysfunction
What are the embolic complications of acute myocardial infarction?
CNS/peripheral embolisation
What are the inflammatory complications of acute myocardial infarction?
Pericarditis
How do we treat ischaemic complications of acute myocardial infarction?
Revascularisation
- PCI
- Coronary artery bypass graft (CABG)
How do we treat mechanical complications of acute myocardial infarction?
Consider surgical intervention
How do we treat arrhythmic complications of acute myocardial infarction?
Anti-arrhythmics
Pacemaker
Implantable defibrillator
How do we treat embolic complications of acute myocardial infarction?
Consider
- Anticoagulants
- Antiplatelet drugs
How do we treat inflammatory complications of acute myocardial infarction?
Anti-inflammatory agents
What are the goals of post-hospital management of an acute myocardial infarction?
Modify lifestyle
Modify cardiac risk factors
Medications
How is lifestyle modified?
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
How are cardiac risk factors modified?
Diabetes: management plan Hypercholesterolaemia - Aim for total cholesterol <4.0 mmol/L - Aim for LDL <1.8 mmol/L Hypertension - Salt restriction - Weight reduction
How are medications managed after an acute myocardial infarction?
Ensure medications used instituted and tolerated
Explain role of each drug to patient > improves compliance
Review medication chart at each review
