Ischaemic heart disease (angina and MI)

Question 1

How is “ischaemic heart disease” divided?

Answer 1

Stable angina

ACS (further divided into unstable angina, non ST-elevation myocardial infarction, STEMI)

Question 2

What are the most sensitive and specific markers of myocardial necrosis?

Answer 2

Troponins I and T

Question 3

What qualifies as ST elevation?

Answer 3

>1mm in more than 2 contiguous inferior leads (II, III, avF, avL)

>2mm in at least two chest leads (V1-V6)

Question 4

How is stable angina managed?

Answer 4

GTN for symptom relief

B-blockers (if not contraindicated)

Verapamil, diltiazem

Stenting

CABG for three-vesse disease

Question 5

What agents are used to thrombolyse?

Answer 5

Streptokinase, recombinant tissue plasminogen activators

Question 6

Pharmacological secondary prevention of MI?

Answer 6

Dual antiplatelets, ACE inhibitors, Beta-blockers and statins (as well as other risk factors)

Question 7

If a calcium channel blocker is used as monotherapy for angina, what type should it be? If used in conjunction with a beta blocker what should be used instead?

Answer 7

Rate limiting e.g. verapamil, diltiazem

Dihydropyridine, long-acting e.g. modified release nifedipine

Question 8

Which anti-anginal drug causes tolerance?

Answer 8

Isosorbide moninitrate

Question 9

How does ivabradine work?

Answer 9

Acts on the “funny current” at the sino-atrial node; reduces pacemaker activity and hence heart rate

Question 10

How do thrombolytic drugs work?

Answer 10

Activate plasminogen to form plasmin; this degrades fibrin and helps break up thrombus

Question 11

What is the commonest cause of death following myocardial infarction?

Answer 11

Ventricular fibrillation

Question 12

Complications of MI? (9)

Answer 12

Cardiac arrest (V fib)

Cardiogenic shock

Chronic heart failure

Bradyarrythmia (AV block)

Pericarditis

Left ventricular aneurysm

Left ventricular wall rupture

Ventricular septal defect

Mitral regurgitation

Question 13

DDx of new early-to-mid systolic murmur, post-MI? (2)

Answer 13

Acute mitral regurgutation secondary to papillary muscle rupture

Ventricular septal rupture

Question 14

Persistent ST elevation weeks after MI, signs of heart failure?

Answer 14

Left ventricular aneurysm

Question 15

ECG changes and coronary territories:

Posterior

Answer 15

Tall R waves V1-V2

Usually left circumflex, also right coronary

Question 16

Treatment of NSTEMI/unstable angina

Answer 16

Aspirin 300mg, clopidogrel 300mg

Nitrates/morphine PRN for chest pain

Antithrombin treatment (fondaparinux) if not contraindicated

Intravenous tirofibban

Question 17

When would fondaparinux be contraindicated in NSTEMI and what is given instead?

Answer 17

Patient having angiography within 24 hrs; creatinine greater than 265umol/l

Unfractionated heparin

Question 18

Management of STEMI?

Answer 18

Aspirin + P2Y12 receptor antagonist

Unfractionated heparin (if undergoing PCI)

Oxygen if hypoxic

PCI/thrombolysis

Question 19

P2Y12 antagonists?

Answer 19

Clopidogrel, ticagrelor, pasugrel

Question 20

What should happen 90 minutes after thrombolysis?

Answer 20

ECG to see whether ST elevation has resolved; if not adequate resolution then rescue PCI

Question 21

Chest pain in first 48 hours following MI, worse when lying down, associated with pericardial rub?

Answer 21

Pericarditis

Question 22

1-2 week post MI: acute heart failure, raised JVP, dimished heart sounds, pulsus paradoxus?

Answer 22

Left ventricular wall rupture causing tamponade

Question 23

Management of left ventricular wall rupture?

Answer 23

pericardiocentesis and thoractomy

Question 24

First week post MI- acute heart failure, pan-systolic murmur?

Answer 24

DDx- mitral regurgitation, rupture of the interventricular septum