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Ischaemic Heart Disease Flashcards

1
Q

Define Ischaemic Heart Disease?

A

Characterised by decreased blood supply to the heart muscle resulting in chest pain (angina pectoris)

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2
Q

What are the two ways Ischaemic Heart Disease can present?

A

Stable angina or Acute Coronary Syndrome (ACS)

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3
Q

How can ACS be further subdivided into?

A

Unstable angina
NSTEMI
STEMI

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4
Q

What is unstable angina?

A

Chest pain at rest due to ischaemic but without cardiac injury

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5
Q

What is STEMI?

A

ST elevation with transmural infarction

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6
Q

What is MI?

A

Cardiac muscle necrosis resulting from ischaemia

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7
Q

What is the epidemiology of ischaemic heart disease?

A

Common
Prevalence > 2%
More common in males
Annual incidence of MI in the UK ~ 5/1000

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8
Q

When does Angina Pectoris occur?

A

When myocardial oxygen demand exceeds oxygen supply

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9
Q

What is Angina Pectoris due to?

A

Atherosclerosis

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10
Q

What are the rarer causes of angina pectoris?

A

Include coronary artery spasm (e.g. induced by cocaine)
Arteritis
Emboli

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11
Q

What is the pathophysiology of atherosclerosis?

A

Endothelial injury leads to migration of monocytes into the subendothelial space
These monocytes differentiate into macrophages
Macrophages accumulate LDL lipids and become foam cells
These foam cells release growth factors that stimulate smooth muscle, proliferation, production of collagen and proteoglycans
This leads to the formation of an atherosclerotic plaque

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12
Q

What are the risk factors for Ischaemic Heart Disease?

A 
Male 
Diabetes Mellitus 
Family History
Hypertension
Hyperlipidaemia 
Smoking
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13
Q

What are the presenting symptoms of ACS?

A

Acute-onset chest pain
Central, heavy, tight, crushing pain
Radiates to the arms, neck, jaw or epigastrium
Occurs at rest
More severe and frequent pain that previously occuring stable angina

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14
Q

What are the associated symptoms of ACS?

A

Breathlessness
Sweating
Nausea and vomiting
Silent Infacts occur in the elderly and diabetics

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15
Q

What are the presenting symptoms of Stable Angina?

A

Chest pain brought on by exertion and relieved by rest

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16
Q

What are the signs of ACS on physical examination?

A 
Pale 
Sweating
Restless 
Low-grade pyrexia 
Check both radial pulses to rule out aortic dissection
Arrhythmias 
Disturbances of BP
New heart murmus 
Signs of complications
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17
Q

What are signs of complications of ACS on physical examination?

A

Acute heart failure

Cardiogenic Shock

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18
Q

What is important to remember when physically examining for ACS?

A

There may be no clinical signs

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19
Q

What bloods would you do for Ischaemic Heart Disease?

A 
FBC 
U&Es 
CRP 
Glucose 
Lipid profile 
Cardiac enzymes (troponins and CK-MB)
Amylase (pancreatitis could mimic MI)
TFTs
AST and LDH (raised 24 and 48 hours post-MI, respectively)
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20
Q

What do we see on an ECG for unstable Angina or NSTEMI?

A

May show ST depression or T wave inversion

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21
Q

What would we see on an ECG with STEMI?

A

Hyperacute T waves
ST elevation (> 1 mm in limb leads, > 2 mm in chest leads)
New-onset LBBB
Later changes: T wave inversion and Pathological Q waves

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22
Q

What is the relationship between ECG leads and the side of the heart?

A

Inferior: II, III, aVF
Anterior: V1-V5/6
Lateral: I, aVL, V5/6
Posterior: Tall R wave and ST depression in V1-3

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23
Q

How do we use CXR in ischaemic heart disease investigations?

A

Check for signs of heart failure

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24
Q

What are the indications for an Exercise ECG in Ischaemic Heart Disease?

A

Patient with troponin-negative ACS or stable angina with a high pretest probability of coronary heart disease
Pretest probability is based on characteristics of chest pain, cardiac risk factors, age and gender
Digoxin is associated with giving a false-positive result

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25
What is the positive test of an Exercise ECG?
> 1mm horizontal or downsloping ST depression measured at 80 ms after the end of the QRS complex
26
What is the failed test for an Exercise ECG?
Failure to achieve at least 85% of the predicted maximal heart rate (220-age) and otherwise negative findings (no chest pain or ECG changes)
27
What are some resting ECG abnormalities?
pre-excitation syndrome >1mm ST depression LBBB or pacemaker ventricular rhythm
28
How do we use Radionuclide Myocardial Perfusion Imaging (rMPI)?
Uses Technetium-99m sestamibi or tetrofosmin Can be performed under stress or at rest Stress testing shows low uptake in ischaemic myocardium
29
How do we use an Echocardiogram in Ischaemic Heart Disease?
Measures left ventricular ejection fraction | Exercise or dobutamine stress echo may detect regional wall motion abnormalities
30
When do we do Pharmacological Stress Testing?
This is used in patients who are unable to exercise Pharmacological agents can be used to induce a tachycardia These agents are used in conjuction with various imaging modalities to detect ischaemic myocardium
31
What are the pharmacological agents that can be used to induce tachycardia?
Dipyridamole Adenosine Dobutamine
32
When are Dypiridamole and Adenosine contraindicated?
In AV block and reactive airway disease
33
When is Cardiac Catheterisation/Angiography used?
Perfomed if ACS with positive troponin or if high risk on stress testing
34
What is Coronary Calcium scoring and when is it used?
Uses specialised CT scan | May be useful in outpatients with atypical chest pain or in acute chest pain that isn't clearly due to ischaemia
35
What is the management plan for Stable Angina?
``` Minimise cardiac risk factors Immediate symptom relief Long-term management Percutaneous Coronary Intervention (PCI) Coronary Artery Bypass Graft (CABG) ```
36
What are cardiac risk factors that should be minimised?
BP Hyperlipidaemia Diabetes
37
What should all patients receive?
Aspirin 75 mg/day unless contraindicated
38
What can be used for immediate symptom relief?
GTN spray
39
What is the long-term management of a stable angina?
Beta-Blockers Calcium Channel blockers Nitrates
40
When is Beta-blockers contraindicated?
``` Acute Heart Failure Cardiogenic Shock Bradycardia Heart Block Asthma ```
41
When is Percutaneous Coronary Intervention (PCI) performed?
In patients with stable angina despite maximal tolerable medical therapy
42
What is an example of a situation when CABG is done?
Occurs in more severe cases | E.g. three-vessel disease
43
What is the management plan for unstable angina/NSTEMI?
``` Admit to coronary care unit Oxygen, IV access, monitor vital signs and serial ECG GTN Morphine Metroclopramide Aspirin Clopidogrel LMWH Beta-Blocker Glucose-Insulin infusion ```
44
Why do we adminster Metoclopramide?
To counteract the nausea caused by morphine
45
Wnat is the Aspirin dose in the treatment of Unstable Angina/NSTEMI?
300 mg initially, followed by 75 mg indefinitely
46
What is the Clopidogrel dose for the treatment of Unstable Angina/NSTEMI?
300 mg initially, followed by 75mg for at least 1 year if troponin positive or high risk
47
When do we do a Glucose-insulin infusion in the treatment of Unstable Angina/NSTEMI?
If blood glucose > 11 mmoll/L
48
Why might we consider GlpIIb/IIIa inhibitors in patients with Unstable Angina/NSTEMI?
In patients: undergoing PCI At high risk of further cardiac events
49
What do we do if there is little improvement following treatment of an Unstable Angina/NSTEMI?
Consider urgent angiography with/without revascularisation
50
What is a mneumonic to remember the acute management of ACS?
``` MONOBASH: Morphine Oxygen Nitrates Anticoagulants (aspirin + clopidogrel) Beta-blockers ACE inhibitors Statins Heparin ```
51
What is the difference between STEMI management and UAP/NSTEMI management?
Clopidrogrel 600mg if patient is going to PCI 300 mg if undergoing thrombolysis and < 75 yrs 75mg if undergoing thrombolysis and > 75 yrs
52
What is the goal of Primary PCI in management of STEMI?
Goal < 90 min if available
53
What is the secondary prevention of the management of STEMI?
``` Dual antiplatelet therapy (aspirin + clopidogrel) Beta-blockers ACE inhibitors Statins Control risk factors ```
54
What advice would you give to someone who has had a STEMI?
No driving for 1 month following MI
55
When is CABG considered?
In patients with left main stem or three-vessel disease
56
What are the early complications of Ischaemic Heart Disease (within 24-72 hrs)?
``` Death Cardiogenic Shock Heart Failure Ventricular Arrhythmias Heart Block Pericarditis Myocardial rupture Thromboembolism ```
57
What are the late complications of ischaemic heart disease?
``` Ventricular Wall Rupture Valvular Regurgitation Ventricular Aneurysms Tamponade Dressler's Syndrome Thromboembolism ```
58
What is the mnemonic for complications of MI?
``` DARTHVADE Death Arrhythmias Rupture Tamponade Heart Failure Valve disease Aneurysm Dressler's Syndrome Embolism ```
59
What are the two types of ways you can do to summarise the prognosis for patients with ischaemic heart disease?
TIMI Score | Killip classification
60
What are TIMI scores?
``` TIMI score (0-7) can be used for risk stratification Note: TIMI = thrombolysis in MI High scores are associated with high risk of cardiac events within 30 days of MI ```
61
What are the Killip classification?
Class I: no evidence of heart failure Class II: mild to moderate heart failure Class III: over pulmonary oedema Class IV: cardiogenic shock

Acute Care & Trauma (25 decks)

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