lecture 2 - coronary artery disease

Question 1

CVD in men v women?

Answer 1

more in men

Question 2

CAD modifiable risk factors

Answer 2

Modifiable
• Smoking
• Diabetes mellitus
• Hypertension
• Dyslipidaemia

Question 3

CAD non-modifiable risk factors

Answer 3

Non-modifiable
• Genes (family history)
• Age
• Males (and post-menopausal
females)
• Ethnicity

Question 4

Canadian Cardiovascular Society (CCS) Classification of angina

Answer 4

• CCS class I: angina with strenuous or prolonged exertion only

• CCS class II: angina when walking uphill rapidly, or 100-200
metres on the flat, or during emotional states

• CCS class III: angina when climbing one flight of stairs
• CCS class IV: angina at rest or with minimal physical activity

Question 5

investigations to do in someone presenting with stable angina

Answer 5

Investigations

• Blood tests: U&Es, LFTs, FBC, fasting lipids, fasting glucose, clotting
• Resting 12-lead ECG (may be normal)

• Non-invasive test – if intermediate likelihood (10-60%)
– Stress echocardiography
– SPECT (or PET) myocardial perfusion scintigraphy
– First-pass contrast-enhanced magnetic resonance perfusion imaging
or stress magnetic resonance imaging
– CT coronary calcium score

• Invasive x-ray coronary angiography – if high likelihood (>60%)
or positive non-invasive test

Question 6

use of Stress Echocardiography

Answer 6

Based on detection of new regional wall motion abnormality on stress
(dobutamine or exercise) as marker of ischaemia.

Question 7

use of Myocardial Perfusion Scintigraphy

Answer 7

Based on myocardial radiopharmaceutical uptake during vasodilator (usually
adenosine or adenosine agonist) stress compared to rest imaging.

good at assessing the thickness of the cardiac wall affected by inducible ischaemia

Question 8

Magnetic Resonance Perfusion Imaging

Answer 8

Based on first-pass contrast-enhanced (gadolinium) imaging on the
myocardium with vasodilator (adenosine) stress.

Question 9

CT Coronary Calcium Score

Answer 9

A low coronary calcium score
(Agatston score = 0) makes the presence of obstructive CAD very unlikely and is consistent with a low risk of cardiac event in the next 2-5 years (0.1% annual risk).

A high coronary calcium score
(Agatston score >100) is
consistent with a high risk of
cardiac event in the next 2-5
years (>2% annual risk).

Question 10

stable angina Treatment – Risk Factor Modification

Answer 10

Treatment – Risk Factor Modification

• Stop smoking
• Treat hypertension
• Treat dyslipidaemia
• Optimise diabetic control
• Lose weight
• Take regular exercise
• Optimise diet

Question 11

Stable Angina Treatment – Pharmacological Treatment

Answer 11

• Aspirin

• Anti-anginal agents – work by increasing coronary perfusion
and reducing myocardial oxygen demand:
– beta blockers, e.g. bisoprolol, carvedilol
– calcium antagonists, e.g. amlodipine, diltiazem
– potassium channel activators – nicorandil
– nitrates, e.g. isosorbide mononitrate, glyceryl trinitrate
– late sodium channel blocker – ranolazine
– mixed sodium/potassium channel blocker (“funny” current blocker) –
ivabradine

Question 12

Stable Angina Treatment – Revascularisation

Answer 12

Treatment – Revascularisation

• Revascularisation should be considered in:
– stable angina resistant to medical therapy
– prognostically important coronary artery disease, e.g. left mainstem
disease, triple vessel disease

• Options:
– percutaneous coronary intervention (PCI)
– coronary artery bypass graft surgery (CABG)

Question 13

Acute Coronary Syndrome Clinical Features

Answer 13

• = syndrome of anginal pain at rest
• Often associated with breathlessness
and autonomic symptoms (nausea,
dizziness)
• Physical signs may be absent or subtle
(tachypnoea, tachycardia) in
uncomplicated ACS
• Can be complicated by heart failure,
cardiogenic shock or arrhythmia

Question 14

Acute Coronary Syndrome Clinical Spectrum

Answer 14

Name, Cardiac Enzymes/Troponin, ECG

Unstable angina * Negative. ST depression, T wave changes or normal

NSTEMI * Positive. ST depression, T wave changes or
normal

STEMI Positive. ST elevation or new LBBB

Question 15

Acute Coronary Syndrome Investigations

Answer 15

• ECG
• Blood tests: U&Es, LFTs, CRP, FBC, clotting screen, G&S,
cholesterol, glucose
• Chest x-ray
• Coronary angiography (for primary PCI) – immediate if STEMI
within 12 hours of onset of pain
• Echocardiography – later unless prominent HF

Question 16

Acute Coronary Syndrome Risk Stratification (for NSTEACS)

Answer 16

GRACE score - give probability of death or MI in hospital and at 6 months. based on age, HR, SBP, creatine, CHF, cardiac arrest at admission, ST segment deviation, elevated cardiac enzymes/markers.

Question 17

Acute Coronary Syndrome Treatment – Immediate

Answer 17

• Oxygen
• Aspirin 300 mg stat, then 75 mg od
• Clopidogrel 300 or 600 mg stat, then 75 mg od (c.f. prasugrel
and ticagrelor)
• Low molecular weight heparin, e.g. fondaparinux
• ± Opiate analgesia (e.g. morphine 5 mg IV) + anti-emetic
• ± Sublingual and/or intravenous glyceryl trinitrate
• Primary PCI or thrombolysis if STEMI within 12 hours of pain
• Cardiac monitoring

Question 18

Acute Coronary Syndrome Treatment – Later

Answer 18

• Start secondary prevention agents:
– beta blockers
– ACE inhibitor
– statin
• Coronary angioram ± PCI if NSTEACS
• Tailored lifestyle advice, e.g. return to work, driving, flying
• Cardiac rehabilitation

Question 19

Acute Coronary Syndrome Complications

Answer 19

• Valvular dysfunction
– inferior MI associated with mitral regurgitation due to papillary
muscle dysfunction or rupture

• Cardiac rupture
– rupture of the interventricular septum leads to VSD
– rupture of free wall leads to haemopericardium ± tamponade

• Heart failure and cardiogenic shock
• Arrhythmias