Ischemic heart disease Flashcards by Adele Atkins

What is cardiovascular disease?

A disease of the heart or circulatory system which comprises coronary heart disease, cerebrovascular disease and peripheral vascular disease

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Which study determined the concept of risk factors in cardiovascular disease?

Framingham heart study

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List the controllable risk factors of coronary heart disease

Cigarette Smoking
Diabetes
High blood pressure
High cholesterol
Obesity

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List the non controllable risk factors of coronary heart disease

Age
Gender
Family history of premature coronary disease
Previous heart attack

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What does atherosclerosis involve?

Development of a fatty streak
Lipid deposition
Intimal fibrosis

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How does ischemic heart disease develop?

Atherosclerotic plaque build up within one or more coronary arteries, obstructing myocardial blood flow

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What does the process of ischemic heart disease development cause?

This leads to an imbalance between myocardial oxygen supply and demand
Restricts normal increase in coronary blood flow in response to increase in myocardial oxygen demand

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List the clinical manifestations of ischemic heart disease

Asymptomatic
Stable angina
Acute coronary syndromes - (Unstable angina, NSTEMI, STEMI)
Long-term - (Heart failure, Arrhythmias, Sudden death)

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Define stable angina

Ischemia due to fixed atheromatous stenosis of 1 or more coronary arteries

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Define unstable angina

Ischemia caused by dynamic obstruction of a coronary artery due to a plaque rupture with superimposed thrombosis and spasm
Angina at rest ( > 20mins)
New onset ( < 2 months) exertional angina (at least CCS III in severity)
Recent ( < 2months) acceleration of angina (increase in severity of at least one CCS class to at least III)
Normal cardiac biomarkers (troponin)

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Define myocardial infarction

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

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Define heart failure

Myocardial dysfunction due to ischemia/infarction

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Define arrythmia

Altered conduction due to ischemia or infarction

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Define sudden death

Ventricular arrhythmia, asystole or massive myocardial infarction

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State and define the classification of angina

Class I: Ordinary physical activity (such as walking and climbing stairs) does not cause angina
Class II: Angina causes slight limitation of ordinary physical activity
Class III: Angina causes marked limitation of ordinary physical activity
Class IV: Inability to perform any physical activity without angina

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Define typical angina

Meets all 3 of the following characteristics:
Substernal chest discomfort of characteristic quality and duration
Provoked by exertion or emotional stress
Relieved by rest and nitrates within minutes

Define atypical angina

Where only 2 of the required characteristics to diagnose typical angina are met

Describe some ways of managing a patient with angina

Short acting nitrates
Beta blockers
PCI, Stenting or CABG
Lifestyle management 
Control of risk factors
Education

What does the definition of the type of MI depend on?

The findings on the ECG

Name the 2 different types of MI

STEMI

NSTEMI

In hospitals which type of MI has associated higher death rates?

STEMI

Which type of MI causes an increase in the chance of the patient dying in the long term?

NSTEMI

What is ACS characterised by?

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

What do acute coronary syndromes consist of?

Unstable angina and myocardial infarcts

Following plaque disruption, thrombus results from...

Adherence, activation and aggregation of platelets Thrombin and fibrin production via the coagulation cascade (and thrombin release from platelets) Vasoactive molecules released from platelets which cause vasoconstriction

What does a STEMI look like on an ECG?

ST elevation

What is an ST elevation a sign of?

Complete coronary occlusion

What does a NSTEMI look like on an ECG?

ST depression or normal ECG

What does a NSTEMI ECG signify?

Incomplete occlusion

What are the classical symptoms at presentation of ACS?

Discomfort/pain in the centre of the chest that lasts for more than a few minutes or recurs Discomfort/pain radiating to other areas, e.g. arms/jaw/back Not relieved immediately with S/L GTN

What are the symptoms more commonly present with ACS in elderly or diabetic patients?

Elderly or diabetic patients often present with: Breathlessness Nausea or vomiting Sweating and clamminess

Which immediate assessments do you do when investigating a suspected ACS?

``` Patient history ECG Physical examination Risk stratification Cardiac biomarkers (troponin) ```

What are the therapeutic goals in ACS?

Restore coronary artery patency (STEMI) Limit myocardial necrosis (STEMI) Control symptoms

State the medical management in ACS

Anti-platelet therapy Anti-ischaemic therapy Secondary prevention

Describe secondary prevention methods for ACS

``` Antiplatelet therapy Aspirin Ticagrelor /clopidogrel /prasugrel Statin ACE inhibitors Beta blockers Smoking cessation Lifestyle modification ```

State the rapid treatment given in STEMI

Morphine and/or nitrates for pain relief Antiplatelet agents (aspirin + ticagrelor*) *Clopidogrel in high risk bleeding populations AND ‘Primary’ angioplasty (balloons, stents): artery is mechanically reopened, restoring blood flow “Clot-busting” drug (thrombolysis): pharmacologically break up clots, restoring blood flow when access to angioplasty delayed/unavailable

Define NSTEMI

Defined as the absence of persistent ST elevation (<20 minutes) on ECG, but with angina symptoms and elevated cardiac biomarkers

Who are the high risk patients?

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

Describe the management of UA/NSTEMI

``` Analgesia Antiplatelet therapy Anti-ischaemic therapy Statins Early coronary angiography with a view to revascularisation (stenting or CABG) ```