Ischaemic heart disease and acute coronary syndromes

Question 1

Describe the sequence of changes seen on ECG during evolution of STEMI

Answer 1

Normal
Peaked T wave
Degrees of ST elevation 
Q wave formation and loss of R wave- caused by fibrosis 
T wave inversion

Question 2

How does a heart attack happen?

Answer 2

Heart disease develops over time as fatty deposits narrow coronary arteries, restricting blood flow to the heart
Coronary artery blocks
Blood flow is restricted and a heart attack begins
If blockage continues, parts of the heart muscle start to die
Heart may stop beating, leading to cardiac arrest

Question 3

What stops a heart attack?

Answer 3

Quick action and medical treatment restores blood flow and saves heart muscle
Time is muscle

Question 4

Describe the rapid treatment of STEMI

Answer 4

Antiplatelet agents (aspirin + clopidogrel)
AND
“Clot-busting” drug (thrombolysis): pharmacologically break up clots, restoring blood flow
‘Primary’ angioplasty (balloons, stents): artery is mechanically reopened, restoring blood flow

Question 5

State and describe some revascularization therapies used in STEMI

Answer 5

Primary PCI
The NIAP* suggests that PPCI is most effective if delivered within 150mins of the patient’s call for help (‘call-to-balloon’ time)

Thrombolysis:
Treatment of choice in STEMI when primary PCI cannot be performed
Aim to initiate within 90mins of patient calling for help (‘call-to-needle’) or within 30mins of arrival at hospital (‘door-to-needle’)

Question 6

List some limitations of thrombolysis

Answer 6

Only 50% restore normal coronary flow after 90 minutes
Increased bleeding risks with thrombolysis (haemorrhagic stroke)
Lack of reliable non-invasive methods for assessing patency of infarct related artery

Question 7

Describe the warning symptoms of an MI

Answer 7

Chest discomfort—pressure, squeezing, fullness or pain in center of chest
Discomfort in arm(s), back, neck, jaw or stomach
Shortness of breath
Breaking out in a cold sweat
Nausea
Light-headedness

Question 8

List some groups of people where the presentation of an MI is considered atypical

Answer 8

Women- present later with atypical symptoms of nausea, breathlessness, shortness of breath, back ache
Elderly - Confusion, Collapse, pneumonia
In context of pneumonia etc.
Diabetics - ‘silent’, DKA, SOB

Question 9

What are the advantages of calling 999?

Answer 9

Brings emergency personnel who can:
Arrive fast and commence medical care
Send information to hospital ED before the patient’s arrival
Defibrillation if patient goes into cardiac arrest

Question 10

List the complications of coronary angioplasty

Answer 10

Myocardial infarction
Stroke
Arrhythmias
Renal failure- large volume of contrast or if the patient already has renal problems 
Vascular injury
Contrast reactions
Coronary artery dissection- from insertion of the balloon 
Emergency surgery
Death

Question 11

What is monitored during a coronary angioplasty?

Answer 11

Blood pressure
Oxygen saturations
ECG – ST segments
Arrhythmias - Bradycardia or Tachycardias

Question 12

Define cardiac rehabilitation

Answer 12

“The coordinated sum of activities* required to influence favorably the underlying cause of cardiovascular disease as well as to provide the best possible physical, mental and social conditions, so that patients may by their own efforts, preserve or resume optimal functioning in their community and through improved health behavior, slow or reverse progression of disease’’.

Question 13

List some goals for cardiac rehabilitation

Answer 13

Recovery
Secondary Prevention
Adoption & Maintenance of Healthy Lifestyle
Preservation of Mobility and Self-Sufficiency
Return to Work
Cost-Effectiveness for the Health Service

Question 14

List some components of cardiac rehabilitation

Answer 14

Exercise
Education
Psychological support
Risk factor modification
Medical Risk Management

Question 15

How is cardiac rehabilitation delivered?

Answer 15

Multidisciplinary team approach
Cardiac rehabilitation specialist nurses
Physiotherapists
Dietician
Administrator
Clinical lead
Psychologist/Psychology practitioners
Pharmacist
Occupational therapist

Question 16

What are the key priorities for MI patients following the event?

Answer 16

Cardiac rehabilitation to begin as soon as possible after admission
Lifestyle changes to include information on diet,activity,smoking
Drug therapy treatment and offer an assessment of left ventricular function to all patients who have had an M.I.
Communication of diagnosis and advice on secondary prevention, including future management plan

Question 17

Describe the psychological impact of a cardiac event

Answer 17

Anxiety and depression, if not treated or managed can lead to poor cardiac rehabilitation outcomes.
All patients should undergo a valid assessment including anxiety and depression ,assessment of other relevant psychological factors
Agreed referral pathway to appropriately trained professionals for individuals with clinical levels of anxiety or depression and for those demonstrating signs of psychological illness.

Question 18

List some of the physiological challenges for patients who have CHD

Answer 18

Frightening, life-threatening event
Medication side effects
Fears for family and partner being left alone
Threat to employment and financial status
Being treated differently by other people
Neurological impairment
Making lifestyle changes

Question 19

Why are distressed CHD patients a problem?

Answer 19

Distressed CHD patients have:
Significantly higher rates of hospitalisation
Significantly higher rates of cardiac events
Therefore most cost to the health service

Question 20

List some contraindications to exercise following a cardiac event

Answer 20

Fever and acute systemic illness
Unresolved unstable angina
Resting BP: Systolic > 200 mmHg, Diastolic > 110 mmHg 
Critical aortic stenosis
Uncontrolled arrhythmias
Acute pericarditis or myocarditis
Acute or unstable heart failure
Breathlessness or palpitations
Dizziness or lethargy
Uncontrolled diabetes
Recently altered ECG response especially ST segment depression
Severe pulmonary, orthopaedic, or metabolic condition that would hinder exercise capacity

Question 21

Education should be culturally sensitive and achieve two main aims…

Answer 21

To increase knowledge and understanding of risk factor reduction
To utilise evidence-based health behaviour change theory in its delivery. Incorporation of both aspects of education increases the probability of successful long- term maintenance of change