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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
What is silent MI
ACS presenting without chest pain In elderly, DM Instead: syncope, pulmonary oedema, acute confusional state, stroke, hyperglycaemia
26
What tests do you order for ACS
12 lead ECG Bloods: FBC, U+E, glucose, lipids, Troponins (I and T) CXR
27
What are ECG changes in ACS
STEMI: st elevation, new LBBB | NSTEMI/UA: st depression, t wave inversion, normal
28
What are sequential ECG changes following MI
Hrs: ST elevation Days - weeks: T wave inversion, Q wave develops Months: T wave normalises, Q wave persists
29
What is immediate management of STEMI
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
What is given in fibrinolysis
Tissue plasminogen activator: Tenecteplase Single IV dose Given within 30mins admission
31
What are contraindications to fibrinolytic therapy
``` Previous intracranial haemorrhage Recent ischaemic stroke Recent trauma/surgery/head injury GI bleed Known bleeding disorder Cerebral malignancy Non-compressible punctures ```
32
How do you manage STEMI patients with symptom onset >120 hrs
Anticoagulation: Fondaparinux
33
How do you manage RV infarction
Confirm with rV3/4 on ECG Fluids Avoid nitrates and diuretics May need inotropes
34
How do you manage NSTEMI
``` 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
Who is considered high risk nstemi
Rise in troponin Dynamic ST changes DM, CKD, LVEF <40%, past MI, PCI, CABG, High GRACE score
36
Who is considered low risk NSTEMI
No chest pain No signs of heart failure Normal ecg -ve troponin
37
What are types of antiplatelets used in ACS
Clopidogrel: given on clinical suspicion Ticagrelor: preferred, high risk groups Prasugrel: if undergoing PPCI
38
What is involved in further management of ACS
Symptom Modify risk factors Cardio protection Revascularisation
39
What is involved in modifying risk factors
Smoking cessation Identify + treat DM, HTN, hyperlipidaemia Daily exercise, cardiac rehab Diet: high fibre, fruit, veg, low sat fat
40
What is involved in cardio protective management
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
Who receives Angiography
Immediate: STEMI + high risk NSTEMI 24hrs: mod risk NSTEMI 72hrs: lower risk NSTEMI
42
What are indications for CABG
Triple vessel disease Left mainstream disease (STE In aVR) Angioplasty failed, unsuitable Refractory Angina
43
What are complications of MI
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
What are the types of Bradyarrhthmias | When do they occur and how should they be managed
Sinus bradycardia Heart block Bundle branch block Inferior MI Pacing: mobitz II, complete HB, BBB
45
What are types of tachyarrhythmias post MI
``` Sinus tachycardia SVT AF/flutter Frequent premature ventricular contractions Non-sustained VT (fast PVCs <30s) Sustained VT (fast PVCs >30s) VF ```
46
How do you manage different tachycardias post MIs
``` Correct hypokalaemia, hypomagnesaemia Beta blockers Synchronised DC shock: Sustained VT Anti arrhythmics if not controlled w D DC shock: VF ICD ```
47
What are signs of pericarditis | How do you manage pericarditis
Central CP relieved by leaning forwards ECG: saddle shaped ST elevation NSAIDs
48
How does cardiac tamponade present | How do you treat
Reduced cardiac output Pulsus paradoxus: large drop in stroke volume on inspiration Kussmauls sign: JVP rise on inspiration Muffled heart sounds Pericardial aspiration
49
What is cause of mitral regurgitation | How does this present
Rupture of papillary muscle due to ischaemia | Pansystolic murmur, new onset
50
What is ventricular aneurysm | How might this present and how do to manage
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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