Ischaemic Heart Disease Flashcards
CVD
Disease of heart or coronary system
Comprises of CHD, Cerebrovascular disease and peripheral vascular disease
Controllable risk factors for CHD
Cigarette Smoking Diabetes High blood pressure High cholesterol Obesity
Non-controllable risk factors for CHD
Age
Family history of premature coronary disease
Previous heart attack
Atherosclerosis
Development of: Fatty Streak, lipid deposition and intimal Fibrosis
IHD and MI
IHD occurs due to atherosclerotic build up within one or more CA - obstruct myocardial flow
Imbalance
Clinical manifestations of IHD
Asymptomatic
Stable angina
Long term: HF, arrhythmias and sudden death
Acute coronary syndrome: Unstable angina, NSTEMI, STEMI
Classification of angina
I - Ordinary physical activity
II - Slight limitation of ordinary physical activity
III - Marked limitation
IV - Inability to perform any physical activity without angina
Acute coronary syndrome
Characterised by the development of a thrombosis at the site of acute disruption of an atherosclerotic plaque within the wall of the coronary artery
Following plaque disruption, thrombus develops from
Adherence, activation and aggregation of platelets
Thrombin and fibrin production via the coagulation cascade (and thrombin release from platelets)
Vasoactive molecules released from platelets which cause vasoconstriction
ST elevation on ECG is a marker of
Complete coronary occlusion
ST depression on ECG is a marker of
Incomplete occlusion
Variable T waves abnormalities or normal ECG
Classical ACS symptoms
Discomfort/pain in the centre of the chest that lasts for more than a few minutes or recurs
Discomfort/pain radiating to other areas, e.g. arms/jaw/back
Not relieved immediately with S/L GTN
Classical ACS symptoms - elderly
Breathlessness
Nausea or vomiting
Sweating and clamminess
Immediate assessments
Patient history
ECG
Physical examination
Risk stratification Cardiac biomarkers (troponin)
Patient history
Type and site of pain
Time of onset of pain and duration
History of cardiovascular disease/risk factors
Therapeutic goals in ACS
Restore coronary artery patency (STEMI)
Limit myocardial necrosis (STEMI)
Control symptoms
Medical management in ACS
Anti-platelet therapy
Anti-ischaemic therapy
Secondary prevention
Secondary prevention in ACS
Antiplatelet therapy (Aspirin & Ticagrelor /clopidogrel /prasugrel)
Statin ACE inhibitors Beta blockers Smoking cessation Lifestyle modification
Importance of rapid treatment in STEMI n
Morphine and/or nitrates for pain relief Antiplatelet agents (aspirin + ticagrelor*)
‘Primary’ angioplasty (balloons, stents): artery is mechanically reopened, restoring blood flow
“Clot-busting” drug (thrombolysis): pharmacologically break up clots, restoring blood flow when access to angioplasty delayed/unavailable
Unstable angina
Angina at rest ( > 20mins)
New onset ( < 2 months) exertional angina (at least CCS III in severity)
Recent ( < 2months) acceleration of angina (increase in severity of at least one CCS class to at least III)
Normal cardiac biomarkers (troponin)
NSTEMI
Defined as the absence of persistent ST elevation (<20 minutes) on ECG, but with angina symptoms and elevated cardiac biomarkers
‘The troponin explosion’ – a positive troponin is NOT synonymous with NSTEMI
High risk patients
Elevated troponin levels Renal impairment Recurrent chest pain Dynamic ST depression or T wave changes on ECG Haemodynamic instability Major arrhythmias Heart failure Elderly
Management of UA/NSTEMI
Analgesia Antiplatelet therapy Anti-ischaemic therapy Statins Early coronary angiography with a view to revascularisation (stenting or CABG)
