Ischaemic Heart Disease including ACS Flashcards
Define Stable Angina [3]
Discomfort in the chest and/or adjacent areas
Associated with myocardial ischemia
But without myocardial necrosis
Name 6 causes of Stable Angina
Think in terms of things that cause:
reduced coronary blood flow, reduced oxygen transport, increased myocardial demand
Obstructive Coronary Atheroma Coronary artery spasm Coronary artery inflammation Anaemia LVH Thyrotoxicosis
What are the risk factors for SIHD? [10]
Old - Race - Male - FH - Smoker
- Low exercise - Poor Diet-
Diabetes - Hypertension - Hypercholesterolaemia
Describe the site, character and radiation of Ischaemic heart pain? [3]
Retrosternal (Centre)
Tight band/pressure or heaviness
Radiates to neck, jaw and medial arms
What triggers [4] and relieves [2] symptoms of SIHD?
Triggered by Stress, exertion, cold weather and large meals
Relieved by rest & GTN spray
What could you see on an examination of a SIHD patient?
6 signs
4 findings of exacerbating/associated conditions
Tar Staining - smoker
Obesity
Tachycardia
Xanthalasma/Corneal Arcus - Hypercholesterolaemia
Hypertensive retinopathy - DM/HTN
Pansystolic murmur at mitral - Mitral Regurgitation
Ejection systolic murmur @ Aortic area - Aortic Stenosis
Associated conditions:
Pallor- Anaemia
Elevated JVP, basal crackles & peripheral oedema - Heart Failure
Hyperreflexia - thyrotoxicosis
Reduced peripheral pulses + abdominal bruit - AAA
How would you investigate suspected SIHD? [5]
What 6 blood tests will u request?
Bloods - FBC, lipid profile, Glc, U&Es , LFTs & thyroid function CXR ECG Exercise Tolerance Test (ETT) Myocardial Perfusion Imaging Coronary Angiography
What would an ECG show in a SIHD patient? [3]
Pathological Q waves indicative of a past MI [1]
High voltages [1], ST depression [1] - Strain pattern indicates LVH
Whats the use of an ETT in a SIHD patient? [1]
What will a positive test show [1]
Can confirm the diagnosis but unsuitable in those that cannot walk for 9 mins
A +ve test shows ST depression
Treatment approach to stable angina
Rx: symptom relief (lower HR + vasodilation) [1] AND influence disease progression [1]
What meds treat the symptoms of angina? [7]
Lower HR: \+ B-blockers, CCBs Vasodilation: \+ Isosorbide Mononitrate \+ Long acting nitrate Influence disease progression: \+ Statins, ACEi, aspirin 75mg
What type of PCI is used in coronary revascularization?
Percutaneous Transluminal Coronary Angioplasty
What are the advantages of CABG over PCI? [2]
CABG is better in multi vessel disease [1]
Unlike PCI it can help prognostically [1] as well as the symptoms.
In what unusual way can SIHD present? [3]
What demographic is this atypical presentation most common? [2]
Without pain but with SOB on exertion, Excessive Fatigue OE and Near Syncope OE.
Usually in people with reduced pain sensation e.g. elderly & diabetics
What is the classification of angina stages? [4]
Canadian Cardiovascular Society scale of Angina Severity (CCS scale):
1 - Asymptomatic unless strenous acitvity
2 - Slight limitation e.g. walking >2 blocks or mu;tiple flights of stairs
3 - Marked Limitation e.g. i flight of stairs
4 - Cant really dress or wash etc
Which long acting nitrates are used? [3]
How are GTN sprays used? [4]
IVABRADINE, NICORANDIL or RANZOLAZINE monotherapy
GTN to prevent and treat angina episodes
- taken before planned exercise and on symptoms
- repeat dose after 5 mins if not resolved
- call ambulance if not resolved 5 mins after taking second dose
Define an ACS? [2]
Any sudden cardiac event [1] suspected to be related to occlusion of the coronary arteries [1]
What is an atypical ACS presentation? [3]
In people with reduced pain sensation such as the elderly, diabetics and women, ACS can present as: SOB
Signs of heart failure (i.e. pulmonary oedema, raised JVP etc)
Nausea/vomiting
But without the classic chest pain
What causes an ACS? [2]
Rupture of thin fibrous cap with exposed necrotic core, highly inflammatory and prothrombotic
Triggers (sub)occlusive thrombus
ACS investigations for diagnosis [2] What is needed for diagnosis of MI [4]
- ECG
- Cardiac biomarkers detect cardiac cell death
Positive cardiac biomarkers + ONE OF:
- Sx of ischemia >20 mins
- New ECG changes in 2 or more contiguous leads
- Evidence of coronary problem on coronary angiogram
- Evidence of new cardiac damage on another test
Initial management for STEMI
ASPIRIN 300 MG loading dose
- PCI +/- stenting, if within 12h of symptom onset and PCI available 120 mins of admission
- Thrombolysis if PCI not available in next 120 mins
- If still ST elevation after thrombolysis, then transfer for PCI if possible
Why cant streptokinase be used more than once? What will be used instead
Its bacterial so the patient will grow immune and may even have an allergic reaction to a 2nd dose. If treatment is needed for a 2nd MI then it will be rtPA.
If theres no ST elevation how do we distinguish between NSTEMI & UAP (unstable angina pectoris?
Blood Tests for biomarkers of myocardial necrosis- cardiac troponin (cTn), specifically type I & T (type C is present in blood anyway)
If present it indicates an NSTEMI & if absent its UAP.
How do we treat NSTEMI/UAP?
Think of the acronym - give egs for each [5]
Specialist things to prescribe [1]
- MONA - aspirin 300mg
- GRACE score estimates 6 month mortality
- Give fondaparinux if no immediate PCI
- Low risk <3% - conservative management: give ticagrelor
- High risk >3% offer PCI, give prasugrel or ticagrelor, give uH.
What is involved in secondary prevention of ACS?
4 lifestyle mods
Rx [6]
Lifestyle modification: - Smoking Cessation - Healthy limits for alcohol consumption - Daily Exercise & healthier diet (with weight loss if applicable)
Medication: -
- Aspirin 75mg + Clopidogrel for 1 year (dual anti-platelet therapy) then aspirin alone indefinitely
- Beta-blockers to reduce average O2 demand of heart (e.g. Metopolol/Atenolol)
- Statins to lower cholesterol & so reduce risk of atheroma
- ACEI/ARB to control BP (e.g. Ramipril/Losarten respectively)
- Mineralocorticoid receptor antagonist (EPLERENONE): if EF<40% and clinical signs HF or DM (assess with echo before discharge)
Why would thrombolytics be contraindicated? Name 5 instances
When theres any chance of bleeding due to injury elsewhere in the body as thrombolytics could impair clotting
Intercranial Haemorrhage - Malignant Intercranial Neoplasm - Ischaemic Stroke - Aortic Dissectoin - Bleeding diathesis (Coagulopathy)
How do GP2b3a receptor blockers work? [2]
The GP2a3b complex is a receptor found on platelets that activates in the presence of fibrinogen. By blocking the receptor platelets arn’t activated and so clotting doesn’t occur.
What do we give following PCI?
Anti-platelets e.g. Aspirin and Clopidogrel for min 12 months
Unfractionated heparin
Troponin is not specific to MI, what are other causes of a rise in troponin [4]
How long before you’d expect a rise in MI?
- Pulmonary embolism
- Sepsis
- Renal failure
- Sub-arachnoid hemorrhage
Elevated in MI within 3-12h after onset of chest pain
5 Types of MI
Describe the difference between Type 1 and 2
Type 1: Spontaneous MI
- Associated with ischemia and due to primary coronary event
- eg plaque erosion, rupture, fissuring or dissection
Type 2
- Due to imbalance in supply and demand of oxygen
- Result of ischemia but not ischemia from thrombosis of coronary artery
5 Types of MI
Describe the 2 classifications of Type 3 MI [2]
Describe the similarities of Type 4 and Type 5 MI [2]
SCD
Verified coronary thrombus by angiography or autopsy
Type 4 and 5 are iatrogenic
- Type 4 - MI associated with PCI
- Type 5- MI associated with CABG
Causes of Type 1 MI
Whats the usual or main cause [1]
Name 5 other causes
Usually - atherosclerosis
Other causes
- Coronary vasospasm eg cocaine, triptans, 5-FU
- Cocaine, triptans, 5-FU (chemotherapy)
- Coronary dissection
- Embolism of material downstream from coronary artery eg from AF
- Inflammation of coronary arteries (vasculitis)
- Radiotherapy to chest can cause fibrosis and stenosis of coronary arteries
NSTEMI VS STEMI - what does it mean in terms of damage to heart muscle?
NSTEMI = partial thickness damage of heart muscle
STEMI full thickness damage
Acute management of ACS [5]
Investigations [1]
Blood tests [4]
- Morphine 5-10mg IV + antiemetic metoclopromide
- Give O2 non-rebreathe (if SpO2 <94%)
- GTN Sub-lingual or IV (ROA)
- Aspirin 300mg
Investigations
- Serial ECGs
Blood tests
- Check not anaemic
- Kidney function
- Cholesterol
- Thyroid
Follow up care post ACS
Review [2]
Review: 5w to review symptoms (SOB, angina, palpitations) and 3m to check lipids
Anti-anginal drugs - Contraindications
Nitrates
Beta blockers
Ivabradine
Ranolazine
Nitrates - HOCM
BB- 2nd degree HB, asthma, severe COPD, severe PVD
Ivabradine - severe liver disease
Ranolazine - severe liver disease
Name 2 contraindications to trimetazidine (anti-anginal)
Parkinsons disease & other movement disorders, including tremor
Renal disease
Contraindications to
CCB - heart rate slowing
CCB - dyhydropyridine
- CCB - heart rate slowing - contraindicated in CHF
- CCB - dyhydropyridine- contraindicated in severe aortic stenosis, HCM
Which two anti-anginals are contraindicated in congestive heart failure
- CCB- HR slowing
- Nicorandil
When would you consider isosorbide mononitrate in patients with angina
- many patients who take nitrates develop tolerance and experience reduced efficacy
NICE advises that patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate
What is defined as significant features of ischaemia on an ECG?
- 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years,
- or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads - new LBBB (LBBB should be considered new unless there is evidence otherwise)
STEMI initial management
PCI
Name 3 medications need to be given
- Prarugrel
- Radial access - give UH + glycoprotein 11b/111a inhibitor
- Drug-eluting stents
STEMI initial management
Fibrinolysis
Give antithrombin at same time like fondaparinux
Following fibrinolysis, give ticagrelor
If ongoing myocardial ischaemia, consider PCI
STEMI initial management
- What if patient is showing signs of cardiogenic shock?
- What if patient is high bleeding risk?
- What if patient is on oral anticoagulants?
- Cardiogenic shock > PCI
- High bleeding risk - swap prasugrel for ticagrelor
- Oral anticoagulants - swap prarugrel for clopidogrel
NSTEMI conservative management
Low grace score ie >3%
Ticagrelor for 1 year
Aspirin 75mg lifelong
Fondaparinux
Drug eluting stents vs bare-metal stents
- stent coated with paclitaxel or rapamycin which inhibit local tissue growth.
- Whilst this reduces restenosis rates, the stent thrombosis rates are increased as the process of stent endothelisation is slowed
Why aspirin lifelong and the length of second anti-platelet is often 1 year?
Following insertion, the most important factor in preventing stent thrombosis is antiplatelet therapy. Aspirin should be continued indefinitely. The length of clopidogrel treatment depends on the type of stent, reason for insertion and consultant preference. Antiplatelets should only be stopped following discussion with the cardiology team (e.g. if the patient is due to have surgery) due to the risk of stent thrombosis.
Percutaneous Coronary Intervention
Peri-procedural complications
- minor bleeding/hematoma at site of vascular access
- retroperitoneal haematoma
- femoral pseudoaneurysm
- Cholesterol embolisation
PCI
Describe presentation of retroperitoneal hematoma
may occur if the puncture site occurs proximal to the inguinal ligament
may be asymptomatic or present with flank pain/hypotension
PCI
Describe presentation of femoral pseudoaneurysm [3]
pulsatile mass, femoral bruit and compromised distal pulses
PCI
Describe presentation of cholesterol embolisation [4]
- occurs due to embolisation of cholesterol released from atherosclerotic plaques
- purpura, livedo reticularis
- renal impairment
- blue toes
DAPT post-PCI
post percutaneous coronary intervention: add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months
Timing of starting eplerenone after an acute MI
should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy - indicated for HF and LVSD.
What are the complications of MI [10]
Papillary muscle rupture, Mitral regurgitation VSD Heart failure Ventricular free wall rupture Pericarditis Cardiac tamponade LV Aneurysm Embolization Organ failure AF, VT, VF: Arrhythmia
Decreased contractility and CO - Cardiac arrest - usually due to VT / VF - Cardiogenic shock HF - R+L - Angina
What does stasis after MI cause? [2] What is the management of this complication [2]
Systemic embolism: from left mural thrombus after large anterior MI; mx is WARFARIN for 3m
What is ventricular free wall rupture?
What area is common and what happens
FATAL Common in LAD area Necrosis decreases strength and blood haemorrhages out of ventricle Cardiac tamponade False aneurysm if contained
Pathophysiology pericarditis post-MI [2]
- Necrotic tissue irritates pericardium
- If fluid accumulates = cardiac tamponade which puts pressure on heart and reduces ventricle filling
What are the signs of papillary muscle rupture [6]
Mitral regurgitation - harsh systolic - pan systolic
SOB - pulmonary edema
Sympathetic activation - tachycardia, N+V, sweating
Chest pain
Shock
Raised JVP
How do you treat papillary muscle rupture [4]
IV nitrates
Inotropes
IABP - intra-aortic balloon pump
Surgery
How do you differentiate between papillary muscle rupture and VSD
Cath lab - angio
ECHO
What are the signs of cardiac tamponade [5]
3 D's - Distended JVP - increased - Decreased BP - Distant / muffled HS SOB Renal failure
When does free wall rupture occur
1-2 weeks after MI
How does rupture present? [5]
Acute HF secondary to tamponade Raised JVP Pulsus paradoxus Diminished HS New murmur
What do you do for rupture / tamponade
URGENT pericardiocentesis
ECHO
Who is more at risk of rupture (free wall or septal) [4]
Elderly
Female
High BP
Anterior MI - LAD
What does septal wall rupture cause?
Same as tamponade / free wall Pansystolic murmur Raised JVP Acute HF secondary to tamponade Pulsus paradoxus Diminshed HS Anterior MI
What are signs of mitral regurgitation [4]
New murmur
Worsening SOB
Increased JVP
Low BP
What will MR lead to [2]
Cardiogenic shock
Heart failure
How do you treat MR [2]
Treat LVF e.g. with vasodilators
Valve replacement is required
What does pericarditis present like [3]
Ix [2]
Central chest pain Better forward Often 1st 24 hours ECG changes ECHO - look for effusion
How do you treat pericarditis [2]
NSAID
Colchicine
What is Dresslers syndrome
Dx [3]
Rx [2]
Autoimmune pericarditis - 1-3 week post MI Recurretn effusion Fever Pericardial rub Anaemia Dx: - ECG shows global ST elevation and T inversion - ECHO - raised inflammatory markers Rx = NSAID and steroid
What else can you get 1-3 week post MI and how do you manage? [2]
Late malignant ventricular arrhythmia
- Avoid hypokalaemia
- 24hr ECG monitoring prior to discharge for large MI
Left Ventricular aneurysm
Onset
Clinical features [3]
Rx [2]
1 month post MI
- Left ventricular failure
- ST elevation in anterior leads
- Angina
- Recurrent VT/systemic embolism
Mx: warfarin +/- excision
PE
Origin of thrombus
How to prevent?
Due to mural thrombus
Consider anti-coagulation for 3 months post MI
What is cardiogenic shock
Inadequate tissue perfusion to meet demands
What causes cardiogenic shock [8]
Post MI Arrhythmia PE Tension pneumothorax Cardiac tamponade Myocarditis Endocarditis Dissection
How do you Dx cardiogenic shock [4]
ECG
U+E, troponin, ABG
CXR
ECHO
How do you Rx shock [6]
Treat MI / reversible cause Admit to CCU Oxygen Diamorphine - pain + anxiety Plasma expander if hypo-perfused Inotropes if overfilled - dobutamine
How do you measure CO / monitor [7]
BP + pulse MAP CVP ABG ECG - every hour until Dx made Urine output
What is sudden cardiac death
Death due to cardiac cause <6 hours from symptom onset
What causes sudden cardiac death [7]
STEMI CAD CABG Embolism HCM Long QT Valvular disease
What is the prognosis of SCD?
Only 2% survive
Most survivors in VT or VF and can be shocked
What are reversible causes of cardiac arrest:
5 H’s
4 T’s
Hypoxia Hypovolaemia Hyperkalaemia Hypoglycaemia Hypocalcaemia
Thrombosis
Tension pneumothorax
Tamponade
Toxin
What rhythm will they be in after SCD? [3]
VT / VF
Asystole
Pulseless electrical activity
How do you treat SCD [2]
What do you do if witnessed on cardiac monitor?
What do you do if not witnessed?
CPR
Defib
Adrenaline if VF / VT after 3rd shock and every 5 minutes if witnessed on cardiac monitor
1 shock + adrenaline if not witnessed on cardiac monitor
Mnemonic for complications
DREAD Death Rupture septum or papillary Oedema / new onset HF Arrhythmia / aneurysm Dresslers'
Indications for temporary pacemaker
symptomatic/haemodynamically unstable bradycardia, not responding to atropine
post-ANTERIOR MI: type 2 or complete heart block
trifascicular block prior to surgery
Indications for temporary pacemaker: would it be indicated in post-inferior MI?
post-INFERIOR MI complete heart block is common and can be managed conservatively if asymptomatic and haemodynamically stable
