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General Medicine > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

What is angina

A

Cardiac chest pain due to reversible myocardial ischaemia

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2
Q

What are the core features of angina

A
  1. Constricting/heavy pain to chest, neck/jaw/shoulders/arms
  2. Symptom brought on by exertion
  3. Symptom relieved by GTN or rest
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3
Q

What are other triggers of angina

A

Exertion
Cold temperature
Heavy meals
Emotion

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4
Q

What are associated symptoms of angina

A

Sweating
Dyspnoea
Nausea
Faintness

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5
Q

What are causes of angina

A

Atheroma

Anaemia
Aortic stenosis
Tachyarrhythmia 
Arteritis 
HCM
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6
Q

What are types of angina

A

Typical
Atypical
Non-anginal

Stable
Unstable

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7
Q

What is stable angina

A

Typical angina relieved by rest

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8
Q

What is unstable angina

A

Angina of increasing frequency and severity, occurs at minimal exertion/rest

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9
Q

What are the types of investigations used for IHD

A

Exercise Stress Test
Angiography: cardiac CT with contrast, transcatheter angiography
Functional imaging: stress echo (exercise or dobutamine induced), cardiac MRI

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10
Q

How do you investigate stable angina

A

ECG
Bloods: Fbc, u+e, lipids, HbA1c
Further investigations: according to Hx of IHD, typical/atypical/non-anginal chest pain

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11
Q

How do you investigate Typical/Atypical angina

A
  1. CT angiography
  2. Stress echo
  3. Transcatheter angiography
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12
Q

How do you investigate atypical angiography

A

Ischaemic changes on ECG: same as typical angina

No changes: no further investigations for IHD

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13
Q

How do you investigate typical angina in previous IHD

A

Start treatment for stable angina

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14
Q

What is management of stable angina

A

Secondary prevention
Symptom relief
Anti-anginal medication
Revascularisation

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15
Q

How do you manage secondary prevention in stable angina

A 
Stop smoking, Diet, exercise
Control DM
Control HTN
Control lipids: artorvastatin 80mg 
Consider ACE-I
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16
Q

What is given for symptom management

A

GTN spray or sublingual tablets

Glyceryltrinitrate

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17
Q

What is given for anti-anginal therapy

A
  1. Beta blockers or CCB:
    Atenolol, Bisoprolol / Amlodipine, diltiazem
  2. Beta blockers + CCB:
    do not combine B.B. w non-dihydropyridine CCB
  3. Long acting Nitrates: isosorbide mononitrate
    4: Ivabradine (If channel inhibitor)
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18
Q

What is given for revascularisation therapy

When is it indicated

A

Symptoms despite optimal medical therapy
Percutaneous coronary intervention
Coronary artery bypass grafting

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19
Q

What is acute coronary syndrome

A

Myocardial infarction and unstable angina

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20
Q

What is myocardial infarction

A

Myocardial cell death due to ischaemia, releasing troponin

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21
Q

What is myocardial ischaemia

A

Lack of blood supply to myocardium, +/- cell death

No release of troponin

22
Q

What are the differences bw STEMI, NSTEMI, unstable angina

A

STEMI: ST elevation + troponin
NSTEMI: no ST elevation + troponin
UA: no ST elevation + no troponin

23
Q

What are risk factors of acute coronary syndromes

A

Non-modifiable:
Male, old age, FHx (MI in 1st degree relative <55)

Modifiable:
Smoking, obesity, DM, hypertension, hyperlipidaemia, cocaine use

24
Q

What are symptoms of ACS

A

Central chest pain
>20 mins
With: sweating, nausea, dyspnoea, palpitations

25
Q

What is silent MI

A

ACS presenting without chest pain
In elderly, DM
Instead: syncope, pulmonary oedema, acute confusional state, stroke, hyperglycaemia

26
Q

What tests do you order for ACS

A

12 lead ECG
Bloods: FBC, U+E, glucose, lipids, Troponins (I and T)
CXR

27
Q

What are ECG changes in ACS

A

STEMI: st elevation, new LBBB

NSTEMI/UA: st depression, t wave inversion, normal

28
Q

What are sequential ECG changes following MI

A

Hrs: ST elevation
Days - weeks: T wave inversion, Q wave develops
Months: T wave normalises, Q wave persists

29
Q

What is immediate management of STEMI

A

Brief assessment: Hx, Exam, ECG, Bloods, CXR
Aspirin + Ticagrelor (Prasugrel if no Hx of stroke)
IV morphine + metoclopramide
GTN NOT used

Symptom onset <12hrs and PCI available in 120mins:
Bivalirudin (anticoagulant)
PPCI

Symptom onset <12hrs and PCI not available: Fibrinolysis
Rescue PCI (if unsuccessful) or angiography
30
Q

What is given in fibrinolysis

A

Tissue plasminogen activator:
Tenecteplase
Single IV dose
Given within 30mins admission

31
Q

What are contraindications to fibrinolytic therapy

A 
Previous intracranial haemorrhage 
Recent ischaemic stroke 
Recent trauma/surgery/head injury 
GI bleed
Known bleeding disorder 
Cerebral malignancy
Non-compressible punctures
32
Q

How do you manage STEMI patients with symptom onset >120 hrs

A

Anticoagulation: Fondaparinux

33
Q

How do you manage RV infarction

A

Confirm with rV3/4 on ECG
Fluids
Avoid nitrates and diuretics
May need inotropes

34
Q

How do you manage NSTEMI

A 
Assessment: ECG, Hx, exam, bloods, CXR 
Low flow O2
GTN spray, tablets
Aspirin + clopidogrel 
IV Morphine + metoclopramide 
Risk assess - clinical and GRACE score 
High risk: 
Fondaparinux
Aspirin + ticagrelor 
IV nitrate 
Beta blocker 
Angiography

Low risk:
Discharge
Outpatient investigation

35
Q

Who is considered high risk nstemi

A

Rise in troponin
Dynamic ST changes
DM, CKD, LVEF <40%, past MI, PCI, CABG, High GRACE score

36
Q

Who is considered low risk NSTEMI

A

No chest pain
No signs of heart failure
Normal ecg
-ve troponin

37
Q

What are types of antiplatelets used in ACS

A

Clopidogrel: given on clinical suspicion
Ticagrelor: preferred, high risk groups
Prasugrel: if undergoing PPCI

38
Q

What is involved in further management of ACS

A

Symptom
Modify risk factors
Cardio protection
Revascularisation

39
Q

What is involved in modifying risk factors

A

Smoking cessation
Identify + treat DM, HTN, hyperlipidaemia
Daily exercise, cardiac rehab
Diet: high fibre, fruit, veg, low sat fat

40
Q

What is involved in cardio protective management

A

Aspirin + clopidogrel: dual antiplatelet therapy for 12 months
Fondaparinux: Anticoagulate until discharge
Artorvastatin 80mg: High dose statin
Beta blocker
Ace inhibitor: if LVD, HTN, DM

41
Q

Who receives Angiography

A

Immediate: STEMI + high risk NSTEMI

24hrs: mod risk NSTEMI
72hrs: lower risk NSTEMI

42
Q

What are indications for CABG

A

Triple vessel disease
Left mainstream disease (STE In aVR)

Angioplasty failed, unsuitable
Refractory Angina

43
Q

What are complications of MI

A

Cardiogenic shock
Cardiac arrest
Left ventricular failure

Bradyarrhythmia
Tachyarrhythmia

Right ventricular failure
Pericarditis
Cardiac tamponade 
Ventricular aneurysm 
Systemic embolism 
Rupture of Free wall of ventricle 
Ventricular septal defect 
Mitral regurgitation
44
Q

What are the types of Bradyarrhthmias

When do they occur and how should they be managed

A

Sinus bradycardia
Heart block
Bundle branch block

Inferior MI

Pacing: mobitz II, complete HB, BBB

45
Q

What are types of tachyarrhythmias post MI

A 
Sinus tachycardia 
SVT
AF/flutter 
Frequent premature ventricular contractions
Non-sustained VT (fast PVCs <30s) 
Sustained VT (fast PVCs >30s) 
VF
46
Q

How do you manage different tachycardias post MIs

A 
Correct hypokalaemia, hypomagnesaemia
Beta blockers 
Synchronised DC shock: Sustained VT
Anti arrhythmics if not controlled w D
DC shock: VF 
ICD
47
Q

What are signs of pericarditis

How do you manage pericarditis

A

Central CP relieved by leaning forwards
ECG: saddle shaped ST elevation

NSAIDs

48
Q

How does cardiac tamponade present

How do you treat

A

Reduced cardiac output
Pulsus paradoxus: large drop in stroke volume on inspiration
Kussmauls sign: JVP rise on inspiration
Muffled heart sounds

Pericardial aspiration

49
Q

What is cause of mitral regurgitation

How does this present

A

Rupture of papillary muscle due to ischaemia

Pansystolic murmur, new onset

50
Q

What is ventricular aneurysm

How might this present and how do to manage

A

Aneurysmal diatation of ventricular wall due to myocardial infarction

Persistent ST elevation
Systemic embolism - LV mural thrombus

Anticoagulation, excision

General Medicine (6 decks)

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