Long Case IHD Flashcards
How would you risk stratify patients with ACS
TABLE5.1 Risk stratification in patients with ischaemic chest pain at rest HIGHEST TO LOWEST RISK 1.ST elevation myocardial infarction 2.ST depression 3.T wave inversion 4 Non-specific ST–T wave changes 5.Normal ECG
- The risk is higher in each group if cardiac biomarkers (troponins) are elevated.
- The risk is higher in each group for patients with previous ischaemic heart disease or diabetes.
- The higher the risk, the more the benefit of aggressive treatment.
Who should not get prasugrel
Patients over 75 years
Previous hemorrhagic stroke
Post ACS what complications should you ask the patient if they had
Arrthymia Heart failure Embolic events Further angina Valve disease (did they need surgery)
What risk factors should you ask about
previous ischaemic heart disease or previous abnormal CT coronary angiogram or calcium score (which may over-diagnose atheroma)
hyperlipidaemia
diabetes mellitus (the increased risk in these patients is as high as that in non-diabetics who have already had an ischaemic event)
hypertension
family history (in particular, first-degree relatives with ischaemic heart disease before the age of 60
smoking (how many; if stopped, how long ago – risk of infarction at 1 year half that of a smokers)
use of oral contraceptives or premature onset of menopause
obesity and physical inactivity
chronic inflammatory diseases, e.g. rheumatoid arthritis, other arthritis, HIV infection
high serum homocysteine levels, which may have been measured if the patient has premature coronary disease and few other risk factors – levels in the top population quintile increase coronary risk twofold; trials of treatment (mostly with folate), however, have been negative and routine treatment is not recommended
long-term use, in high doses, of cyclo-oxygenase 2 (COX-2) inhibitors or other non-steroidal anti-inflammatory drugs (NSAIDs) (which should be stopped)
erectile dysfunction (which often precedes symptomatic ischaemic heart disease and is a marker of endothelial dysfunction).
Remember that the presence of multiple risk factors is more than additive.
Cholesterol target with IHD
below a level of 4 mmol / L of total cholesterol
low-density lipoprotein (LDL) < 1.8
There is some evidence that statins have beneficial effects beyond their effect on lowering cholesterol levels (via anti-inflammatory effects)
What investigations post MI should you ask if they have had
An echocardiogram
An exercise test
Sestamibi or a stress echocardiogram may have been performed to assess ischaemia
myocardial viability (MRI scan).
Cardiac catheterisation is perhaps the most memorable of the investigations for ischaemic heart disease and if negative suggests a cause other than coronary artery disease (e.g. pericarditis).
Which thrombolysis agents have a survival advantage?
What is the risk of these agents
Alteplase and reteplase > streptokinase
Increase risk of cerebral haemorrhage
Can you discuss the long term management post ACS
- ) What medications can you give to improve prognosis post MI
- ) What different revasculrisation techniques do you know and in what situations are they used
- ) Where can complex patients be discussed
Early revascularisation is has prognostic benefit in high risk (STE and troponin) patients
1.) Aspirin +/- clop/tigagrelor
B-blockers once euvolaemic
Ace-i
- )
a. ) Non-Invasive/medical management dependent on patient
b. )Balloon angioplasty - if stenting not an option such as size/site of lesion, suspected poor medication compliance
c. ) Stenting usually with DES - dependant on site/size of lesions
d. ) CABG - e.g. single vessel for LAD disease, triple vessel disease
3.) Heart MDT
Can you discuss the long term management post ACS
- ) What medications can you give to improve prognosis post MI
- ) What different revasculrisation techniques do you know and in what situations are they used
- ) Where can complex patients be discussed
Early revascularisation is has prognostic benefit in high risk (STE and troponin) patients
1.) Aspirin +/- clop/tigagrelor
B-blockers once euvolaemic
Ace-i
Epleronone if EF <40%
- )
a. ) Non-Invasive/medical management dependent on patient
b. )Balloon angioplasty - if stenting not an option such as size/site of lesion, suspected poor medication compliance
c. ) Stenting usually with DES - dependant on site/size of lesions
d. ) CABG - e.g. single vessel for LAD disease, triple vessel disease
3.) Heart MDT
Can you discuss the long term management post ACS
- ) What medications can you give to improve prognosis post MI
- ) What different revasculrisation techniques do you know and in what situations are they used
- ) Where can complex patients be discussed
Early revascularisation is has prognostic benefit in high risk (STE and troponin) patients
1.) Aspirin +/- clop/tigagrelor
B-blockers once euvolaemic
Ace-i
Epleronone if EF <40%
- )
a. ) Non-Invasive/medical management dependent on patient
b. )Balloon angioplasty - if stenting not an option such as size/site of lesion, suspected poor medication compliance
c. ) Stenting usually with DES - dependant on site/size of lesions
d. ) CABG - e.g. single vessel for LAD disease, triple vessel disease
3.) Heart MDT
What secondary prevention techniques post MI do you know
Control of risk factors is vital post MI
Weight and lipid reduction - statin for all who can tolerate it
Refer to cardiac rehabilitation
Smoking
What secondary prevention techniques post MI do you know
Control of risk factors is vital post MI Weight and lipid reduction - statin for all who can tolerate it Refer to cardiac rehabilitation Smoking HTN management
What secondary prevention techniques post MI do you know
Control of risk factors is vital post MI Weight and lipid reduction - statin for all who can tolerate it Refer to cardiac rehabilitation Smoking HTN managememt
What are the surgical risks following ACS and how would you manage a pre-operative cardiac patient for non-cardiac surgery
AHA has developed a stepwise algorithm to help delineate who is safe for surgery or not and when to consider delaying or cancelling nor emergent surgery
This includes…..
The preoperative cardiac evaluation must be carefully tailored to the patient and nature of the surgical illness (e.g., acute surgical emergency vs elective)
Careful teamwork and communication between the patient, primary care physician, anesthesiologist, consultant, and surgeon
AHA guidelines
- Recency of re-vasculrisation
- Any up to date angiograms or coronary evaluation
- Symptoms
- Decompensated heart failure
- Arrhythmia
- Presence/severity of vascular disease
- Co-morbidities e.g. DM/CKD/HTN
- Riskiness of surgery
- Functional capacity
What are the major clinical predictors of increased peri-operative CV risk
- ) Acute MI < 7 days
- ) Recent MI 7-30 days
- ) Unstable or severe angina
- ) Evidence of large ischaemic burden e.g. symptoms or non-invasive testing
- ) Decompensated CCF
- ) Significant arrhythmias - high grade AV block, SVT with uncontrolled rate, symptomatic with known underlying heart disease
- ) Severe valvular disease
