Ischaemic Heart Disease

Question 1

What is ischaemic heart disease?

Answer 1

The formation of an atheroma in the coronary arteries

Question 2

How are atheroma formed?

Answer 2

Endothelial injury
Accumulation of lipids and macrophages (digest LDL)
Migration of smooth muscle cells to the area

Question 3

What are the stages to atheroma formation?

Answer 3

1. Fatty streak
2. Fibro-fatty plaque
3. Complicated plaque
4. Thrombus overlaying

Question 4

What is the next stage after the formation of an atheroma?

Answer 4

Plaque rupture

Question 5

How is an acute MI caused?

Answer 5

Plaque rupture causes activation of the clotting cascade

Thrombus occludes a coronary artery

Question 6

What are the modifiable risk factors for ischaemic heart disease?

Answer 6

Smoking
Hypertension
Obesity
Hypercholesterolaemia
Type 2 diabetes

Question 7

What are the non-modifiable risk factors for ischaemic heart disease?

Answer 7

Family history
Male
Increasing age

Question 8

What are the conditions included in ischaemic heart disease?

Answer 8

Angina
Acute coronary syndrome/MI
Heart failure

Question 9

What is angina?

Answer 9

Myocardial ischaemia which is ‘demand led’

Question 10

What are the symptoms of angina?

Answer 10

Central chest pain or tightness
Pain may radiate to jaw or arms
Pain brought on by exertion and relieved by rest or PRN medication
Dyspnoea
Sweatiness

Question 11

How is angina diagnosed?

Answer 11

Clinical diagnosis

Question 12

What further investigations are done for angina?

Answer 12

ECG
Exercise ECG
Angiography - CT or catheter
Nuclear medicine - perfusion scan

Question 13

Why are further investigations done in angina?

Answer 13

To confirm coronary disease as the cause

Question 14

What is the general management for angina?

Answer 14

Lifestyle
Medication
Revascularisation

Question 15

What medication is used to treat angina?

Answer 15

Aspirin
Beta blockers (cardioselective - atenolol)
Statin
Nitrates (GTN spray for relief, isosorbide mononitrate as prophylaxis)

Question 16

What are the options for revascularisation in angina?

Answer 16

PCI

CABG

Question 17

What does acute coronary syndrome cover?

Answer 17

Unstable angina
NSTEMI
STEMI

Question 18

What is acute coronary syndrome?

Answer 18

Critical ischaemia which is caused by atherosclerotic plaque rupture and dynamic subtotal or complete occlusion of a coronary artery

Question 19

What are the symptoms of a MI?

Answer 19

Central crushing chest pain lasting more than 20 minutes
Pain not relieved by rest or usual medications
May radiate down arm and to jaw
Sweating
Nausea
Dyspnoea

Question 20

How may an MI present in the elderly or diabetic?

Answer 20

Silent with no chest pain and less specific symptoms

Question 21

What is the initial treatment for MI?

Answer 21

Morphine + metoclopramide
Oxygen (if hypoxic)
Nitrates (if hypertensive or acute LVF)
Aspirin
Ticagrelor

Question 22

What is the definitive management for STEMI?

Answer 22

PCI if it can be delivered within 120 minutes of first medical contact
If not - thrombolysis with alteplase

Question 23

What is the definitive management for NSTEMI or unstable angina?

Answer 23

Continuing anti-platelet therapy
Anticoagulation
GTN if chest pain
Beta blocker
If high risk or recurrent symptoms- coronary angiography, may also receive tirofiban

Question 24

When can low risk NSTEMI or unstable angina patients be discharged?

Answer 24

After repeat negative troponins

Question 25

What are some complications of MI?

Answer 25

``` Bradycardia and heart block Tachyarrhythmia (VF) Ventricular septal defect Mitral regurgitation Cardiac rupture/tamponade LV mural thrombus Dressler's syndrome ```

Question 26

What is Dressler's syndrome?

Answer 26

Secondary cause of pericarditis caused by damage to the heart or pericardium

Question 27

What are the symptoms of Dressler's syndrome?

Answer 27

Fever Pleuritic pain Pericarditis May be pericardial effusion

Question 28

Dressler's syndrome is autoimmune mediated, true or false?

Answer 28

True