Ischaemic Heart Disease Flashcards
Define ischaemic heart disease
Reduced blood supply (ischaemia) to heart muscle -> chest pain
• Stable angina
• ACS – unstable angina, NSTEMI, STEMI
Angina pectoris – myocardial oxygen demand exceeds oxygen supply -> chest pain
• Decubitus – occurs when lying down
• Nocturnal – occurs at night; may wake the patient
• Variant (Prinzmetal’s) – coronary artery vasospasm that occurs at rest
• Cardiac syndrome X – angina & +ve exercise test with normal arteries on angiogram
Myocardial infarction – sudden occlusion of coronary artery -> thrombus formation ->
ischaemia -> necrosis
What are the causes/risk factors of ischaemic heart disease?
Atherosclerosis • Male • Family history • Diabetes • Hypertension • Hyperlipidaemia • Smoking • Previous history
What are the symptoms of ischaemic heart disease?
• Chest pain/discomfort - Central, heavy radiating to left arm, jaw, neck, epigastrium - Stable angina: brought on by exertion and relieved by rest - Unstable angina: even at rest • SOB • Nausea and vomiting • Sweating • May be silent in elderly/diabetic
What are the signs of ischaemic heart disease?
- Pale
- Sweating
- Agitated/distressed
What investigations are carried out for ischaemic heart disease?
• Bloods - FBC - U&Es - Glucose - Lipids - Cardiac enzymes – CK-MB, troponin (after 12h) - Amylase – exclude pancreatitis - AST and LDH – after 24 and 48h for retrospective diagnosis • ECG - Unstable angina/NSTEMI ▪ ST depression ▪ T wave inversion o STEMI ▪ ST elevation ▪ New onset LBBB ▪ T wave inversion (hrs) ▪ Q waves (days) • CXR – signs of heart failure, exclude aortic dissection • Exercise ECG • Myocardial perfusion scan – low uptake in ischaemic myocardium • Echocardiogram – measure LVEF and regional wall motion abnormalities • Angiography
What is the management for ischaemic heart disease?
Stable angina Risk factor control • Conservative - Diet – reduce fat - Exercise - Weight loss - Glycaemic control • Medical - BP control – antihypertensives - Statins - Glycaemic control - Antiplatelets e.g. 75mg aspirin or 75mg clopidogrel
Symptomatic relief
• GTN spray
Anti-anginal therapy
• Beta-blockers
• CCBs
• Long acting nitrates e.g. isosorbide mononitrate
Revascularisation
• PCI for single vessel disease
• CABG for LMS disease, 3 vessel disease or reduced EF
Unstable angina/NSTEMI
• Morphine 5-10mg IV and metoclopramide 10mg IV
• Oxygen if O2 sats <94%
• Nitrates – GTN
• Antiplatelets e.g. 300mg loading dose aspirin -> 75 mg indefinitely; 300mg loading
dose clopidogrel -> 75mg for at least 1 year
• Antithrombotics e.g. fondaparinux or LMWH
• Beta-blocker e.g. metoprolol (CCBs if contraindicated)
• Assess CV risk
- High risk: GPIIb/IIIa antagonists e.g. tirofiban or direct thrombin inhibitor –
bivalirudin and angiography <96h
- Low risk: discharge if troponin -ve
STEMI
• Morphine 5-10mg IV and metoclopramide 10mg IV
• Oxygen if O2 sats <94%
• Nitrates – GTN
• Antiplatelets e.g. 300mg loading dose aspirin -> 75 mg indefinitely; 300mg loading
dose clopidogrel -> 75mg for at least 1 year
• Beta-blocker e.g. metoprolol (CCBs if contraindicated)
• Invasive treatment:
- PCI <90 mins plus IV heparin and GPIIb/IIIa inhibitor or direct thrombin
inhibitor – bivalirudin
- Thrombolysis <12h (streptokinase or recombinant tPA – alteplase) plus IV
heparin
Long-term management of ACS
• Antiplatelet therapy (aspirin/clopidogrel)
• ACE-I
• Beta-blockade
• Cardiac rehabilitation (risk factor modification)
• Statins
What are the complications of ischaemic heart disease?
• MI, stroke, PVD
Early (24-72h) • Death • Cardiogenic shock • Heart failure • Ventricular arrhythmia (VT/VF) • Heart block (transient in inferior MI, complete in anterior MI) • Pericarditis • Papillary muscle rupture (severe MR and LVF signs) • Thromboembolism
Late
• Ventricular/septal rupture
• Valvular regurgitation
• Ventricular wall aneurysm (weakness in wall -> fills with blood -> may block outflow)
• Tamponade
• Dressler’s syndrome (autoimmune Abs against myocardial antigens)
• Thromboembolism
