Ischaemic heart disease (CV) Flashcards
Define ischaemic heart disease.
Condition due to narrowing or blockage of coronary arteries, most commonly due to atherosclerosis, resulting in mismatch between myocardial oxygen supply and demand –> inability to provide adequate blood supply to myocardium
What is ischaemic heart disease also known as? (4)
- chronic coronary disease
- coronary artery disease
- coronary heart disease
- coronary disease
What can ischaemic heart disease manifest as? (2)
- stable angina - occurs on exertion, symptoms subside with rest or on administration of GTN
- acute coronary syndrome (unstable angina, NSTEMI, STEMI)
What are the clinical features of ischaemic heart disease? (5)
- angina (typical vs atypical) - retrosternal chest pain, may radiate to arm, neck or jaw
- dyspnoea (on exertion)
- dizziness
- palpitations
- nausea/vomiting
What is the difference between typical and atypical angina?
- typical angina is a symptom complex consistently associated with ischaemic heart disease:
- chest pressure/squeezing lasting several minutes
- provoked by exercise or emotional stress
- relieved by rest or glyceryl trinitrate (GTN)
- atypical angina is defined as chest discomfort with only two characteristics of typical angina (less predictive of ischaemic heart disease but more frequent in women, diabetes, elderly)
What are some risk factors for ischaemic heart disease? (16)
- age and sex
- smoking
- hypertension
- serum lipids and lipoproteins
- diabetes
- inactivity
- diet
- race, ethnicity, geography
- psychosocial factors + social determinants of health
- CKD
- inflammatory and other diseases
- obesity
- substance misuse
- Fx coronary disease
- CRP and other plasma biomarkers
- pollution
What are the first-line investigations for ischaemic heart disease? (4)
- resting ECG
- haemoglobin - anaemia can cause/exacerbate angina
- lipid profile - high LDL=increased risk, high HDL=protective
- fasting blood glucose or HbA1c
What is the best initial test for chest pain?
ECG
What would an ECG show in ischaemic heart disease?
- often normal
- ST-T changes suggestive of ischaemia (e.g. ST depression in V5&V6, non-specific changes in III&aVF)
- pathological Q waves - negative deflection preceding R wave indicative of prior infarction
What is the first-line imaging modality for stable angina and why?
- contrast-enhanced coronary CT angiography (CCTA)
- visualise coronary arteries and determine feasibility of intervention using PCI
What is the first-line management for ischaemic heart disease?
- beta blocker - bisoprolol/atenolol OR
- rate-limiting CCB - verapamil/diltiazem
- both used if one alone not working
- if used in combination with beta blocker, use a longer-acting dihydropyridine CCB e.g. amlodipine, nifedipine as beta blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
- if patient on monotherapy and cannot tolerate addition of beta-blocker/CCB consider: long-acting nitrate, ivabradine, nicorandil, ranolazine
Why should beta-blockers NOT be prescribed concurrently with verapamil (rate-limiting CCB)?
Causes severe bradycardia and complete heart block
When are beta-blockers contraindicated?
Asthma
What is the management for stable angina? (3)
- (beta-blockers)
- antiplatelet (aspirin 75-150mg) +/- anticoagulant
- sublingual glyceryl trinitrate (GTN spray) to abort angina attacks
- statin
BAGS
What are some side effects of GTN spray for stable angina? (5)
- headaches
- flushing
- dizziness
- hypotension
- tachycardia
