Ischaemic Heart Disease

Question 1

What is the surgical technique for coronary revascularisation?

Answer 1

1. Median sternotomy.
2. Long saphenous vein/internal mammary artery.
3. Cardio-pulmonary bypass.
4. Cardioplegia (arrest of cardiac contractions).
5. Overnight in ITU.
6. 7 days in hospital.
7. 2-3 months of work.
8. Risk of graft disease 8-10 years post-op.

Question 2

What are some of the complications of CABG?

Answer 2

Death, stroke, MI, AF, infection, cognitive impairment, sternal malunion, renal failure, failure to recover.

Question 3

What is the PCI technique?

Answer 3

1. Vascular access
2. Anti-platelets and anti-coagulation.
3. Catheter to ostium of coronary artery.
4. Guidewire down vessel.
5. Balloons threaded over wire.
6. Stent implanted.
7. Balloon, catheter and wires removed.

Question 4

When would you be sent for angiography?

Answer 4

If you had severe symptoms and were highe risk.

Question 5

When would revascularisation be a better option than angioplasty?

Answer 5

Multi-vessel disease, left main disease, diabetes, co-morbidities.

Question 6

What could go wrong in angioplasty?

Answer 6

Stroke, contrast nephropathy, bleeding, failure of stent.

Question 7

What are the advantages and disadvantages of using radial artery access for PCI?

Answer 7

Advantages: dual supply to hand, superficial, compressible, no adjacent nerve/vein.
Disadvantages: smaller, prone to spasm, chance of occlusion.

Question 8

What are the advantages of PCI over thrombolysis?

Answer 8

Fewer deaths, fewer strokes, fewer reinfarctions, fewer episodes of recurrent ischaemia, fewer CABGs.

Question 9

What procedure should you carry out for a person with a STEMI?

Answer 9

Primary PCI.

Question 10

For someone with an acute coronary syndrome what should you do?

Answer 10

Angiography with a view to revascularisation.

Question 11

With chronic stable angina, when would you revascularise?

Answer 11

Severe symptoms or high risk patients.

Question 12

Who are the most likely patients to have sudden cardiac death?

Answer 12

People post MI with arrhythmia risk markers.

Question 13

What can cause ventricular fibrillation?

Answer 13

Scar in heart, unstable plaque in electrically sensitive area of heart, occlusion (acute MI), ischaemic cardiomyopathy.

Question 14

What type of diagnosis is angina?

Answer 14

A clinical diagnosis.

Question 15

Other than symptoms, what else can we use to determine likelihood of angina?

Answer 15

Risk factors.

Question 16

When are risk stratification tests less helpful?

Answer 16

If high risk (risk of false negative result) or low risk (risk of false positive result).

Question 17

What are the pros and cons of exercise testing for angina?

Answer 17

Pros: cheap, reproducible, risk stratification (positive test at low workload implies poor prognosis).
Cons: poor diagnostic accuracy in important sub-groups (women respond differently). Submaximal tests.

Question 18

What are the pros and cons of perfusion imaging?

Answer 18

Pros: non-invasive, pharmacological stress in less mobile patients, more precise than ETT, risk stratification.
Cons: radiation, false positives and negatives.

Question 19

What are the pros and cons of CT angiography?

Answer 19

Pros: non-invasive, anatomical data and risk stratification.
Cons: radiation, less precise than catheter angiography (esp when calcium present), cost.

Question 20

What are the pros and cons of catheter angiography?

Answer 20

Pros: gold standard, anatomical and risk stratification, follow-on angioplasty (widening narrowed vessels).
Cons: risk 1:1000 death, stroke, radiation, contrast can cause renal dysfunction rash and nausea.

Question 21

What drugs can be given in angina?

Answer 21

Aspirin, B-blockers (reduces O2 demand), statin, ACEI