Ischeamic heart disease

Question 1

Cardiovascular disease

Answer 1

Disease of the circulatory system which comprises:

• coronary heart disease
• cerebrovascular disease
• peripheral vascular disease

Question 2

Framingham heart study: CVD prevention

Answer 2

Ongoing longitudinal study in 5209 healthy men and women aged 30 to 62 years in framingham MA

Begun in 1948 and is now in its 3rd generation of participants

Is the origin of the term risk factor

Before framingham, the medical profession had little understanding of CVD prevention

Question 3

Controllable risk factors for CHD

Answer 3

Cigarette smoking
Diabetes
High blood pressure
High cholesterol
Obesity

Question 4

Non controllable risk factors for CHD

Answer 4

Age
Family history of premature coronary disease
Previous heart attack

Question 5

Atherosclerosis

Answer 5

Fatty streak
Lipid deposition
Intimal fibrosis

Question 6

Clinical manifestations of IHD

Answer 6

Asymptomatic
Stable angina
Acute coronary syndromes
- unstable angina
- NSTEMI
- STEMI
Long term
- heart failure
- arrhythmias
- sudden dead

Question 7

Stable angina

Answer 7

Ischaemia due to fixed athermatous stenosis of one or more coronary arteries

Question 8

Unstable angina

Answer 8

Ischaemia caused by dynamic obstruction of a coronary artery due to plaque rupture with superimposed thrombosis and spasm

Question 9

Myocardial infarction

Answer 9

Myocardial necrosis caused by acute occlusion of a coronary artery due to plaque rupture and thrombosis

Question 10

Heart failure

Answer 10

Myocardial dysfunction due to infarction or ischaemia

Question 11

Arrhythmia

Answer 11

Altered conduction due to ischaemia or infarction

Question 12

Sudden death

Answer 12

Ventricular arrhythmia, asystole or massive myocardial infarction

Question 13

Class I angina

Answer 13

Ordinary physical activity (such as walking and climbing stairs) does not cause angina

Question 14

Class II angina

Answer 14

Angina causes slight limitation of ordinary physical activity

Question 15

Class III angina

Answer 15

Angina causes marked limitation of ordinary

Question 16

Class IV

Answer 16

Inability to perform any any physical activity without angina

Question 17

Acute coronary syndromes

Answer 17

Includes unstable angina and heart attacks

Question 18

Pathological progression to atherothrombosis

Answer 18

The development of a thombosis at the site of acute disruption of an atherosclerotic plaque within the wall of the coronary artery

Question 19

Thrombus formation

Answer 19

Plaque disruption

Adherence, activation and aggregation of platelets

Thrombin and fibrin production via the coagulation cascade

Vasoactive molecules released from platelets which cause vasoconstriction

Question 20

ACS: classical symptoms at presentation

Answer 20

Classical:

• discomfort/ pain in the centre of the chest lasts more than few minutes/ recurs
• discomfort/ pain radiating to other areas
• not relieved immediately with S/L GTN

Elderly/ diabetic patients:

• breathlessness
• nausea or vomiting
• sweating and clamminess

Question 21

ACS

Answer 21

Acute coronary syndromes

Question 22

Therapeutic goals in ACS

Answer 22

Restore coronary artery patency (STEMI)

Limit myocardial necrosis (STEMI)

Control symptoms

Question 23

Medical management of ACS

Answer 23

Anti-platelet therapy

Anti-ischaemic therapy

Secondary prevention

Question 24

Secondary prevention in ACS

Answer 24

Anti-platelet therapy (aspirin, ticagrelor/ clopidogrel/ prasugrel)
Statin
ACE inhibitors
Beta blockers
Smoking cessation
Lifestyle modificaiton

Question 25

Unstable angina

Answer 25

Angina at rest >20 minutes New onset (<2 months) exertional angina (at least CCS III in severity) Recent (<2 months) acceleration of angina Normal cardiac biomarkers (troponin)

Question 26

NSTEMI

Answer 26

The absence of persistent ST elevation (<20 minutes) on ECG, but with angina symptoms and elevated cardiac biomarkers - pneumonia - pulmonary embolism - pericarditis - sepsis - heart failure - uncontrolled tachyarrhythmia

Question 27

High risk patients

Answer 27

``` Elevated troponin levels Renal impairment Recurrent chest pain Dynamic ST depression or T wave changes on ECG Haemodynamic instability Major arrhythmias Heart failure Elderly ```

Question 28

Management of UA/ NSTEMI

Answer 28

``` Analgesia Antiplatelet therapy Anti- ischaemic therapy Statins Early coronary angiography with a view to revascularisation ```