M103 T3 L7 Flashcards
What are the three types of CVD?
CHD, CVD, PVD
Coronary heart disease
Cerebrovascular disease
Peripheral vascular disease
What are the controllable risk factors for CHD?
Cigarette Smoking
Diabetes, obesity, high cholesterol
High bp
What are the non-controllable risk factors for CHD?
Age / previous heart attack
Family history of premature coronary disease
What are the clinical manifestations of IHD?
can be asymptomatic - silent ischaemia stable angina, arrhythmias acute coronary syndromes NSTEMI, STEMI HF, Sudden death
What are two types of presenting factors in patients with acute coronary syndromes?
patients with unstable angina
patients who had heart attack or an acute myocardial infarction
What are the two types of heart attack?
NSTEMI
STEMI
What are the long term manifestations of IHD?
Heart failure
Arrhythmias
Sudden death
What is the pathology behind stable and unstable angina?
due to a fixed stenosis / narrowing within one or more coronary artery is and then
What is the pathology behind myocardial infarction and heart failure?
myocardial infarction - plaque rupture and thrombosis cause myocardial necrosis
heart failure - myocardial dysfunction due to infarction or ischaemia
What is the pathology behind arrhythmia and sudden death?
arrhythmia - altered conduction due to ischaemia or infarction
sudden death - ventricular arrhythmia, asystole or massive myocardial infarction
What are the three criteria for typical angina?
substernal chest discomfort
provoked by exertion or emotional stress
relieved by rest and/or nitrates within minutes
What are the criteria for atypical angina?
meets two of the three criteria for typical angina
What are the criteria for non-anginal chest pain?
lacks or meets only one of the three criteria for typical angina
What are the first lines of treatment for angina relief?
short acting nitrate - tablet form or spray under tongue
beta blocker / calcium channel blocker
In what conditions is the second line of treatment for angina relief administered?
if the patient is allergic / intolerant to the first line treatment or of the first line treatment
if first line treatment isn’t enough
What is the next step in treatment for angina relief after the second line of treatment
refer the patient for an angiogram allows you to to visualise the heart arteries
can determine where the narrowing is and then physically treat them via stenting or bypass surgery
What is the main difference between NSTEMIs and STEMIs?
the specific pattern of abnormality on the ECG is different - it determines how urgent treatment is
What is the difference between patients with unstable angina and myocardial infarction?
all patients with acute myocardial infarction present with high levels of troponin which is measured in a blood test
if their troponin levels are elevated - heart attack
Why does troponin in the blood indicate myocardial infarction?
troponin is only released into the blood stream following injury to the heart muscle
typically triponin levels can become elevated within three hours of heart attack and can remain elevated in the blood system for up to two weeks
How does a STEMI present on an ECG?
ST elevation on ECG is a marker of complete coronary occlusion
the patient will have a completely blocked artery and will need emergency treatment to reopen this blockage
How does an NSTEMI present on an ECG?
Incomplete occlusion is associated with ST depression, variable T wave abnormalities or with a normal ECG
indicative of unstable angina
Following from plaque disruption, what does a thrombus result 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 are the classical symptoms 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. left arm/jaw/back
Can occur at rest and/or with exertion
Not relieved immediately with sublingual GTN
What are the three differences between ACS and stable angina symptoms?
the chest pain lasts a lot longer with ACS
not relieved immediately with sublingual GTN
can occur at rest and/or with exertion
What symptoms of ACS do elderly or diabetic patients usually present with?
Breathlessness
Nausea or vomiting
Sweating and clamminess
potentially no chest pain at all (especially in diabetics)
Describe the immediate assessment of patients with suspected ACS
Patient history
ECG - if high ST elevation - rushed off to have their artery fixed - angiogram
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
What three types of therapy are used to manage ACS medically?
Anti-platelet therapy
Anti-ischaemic therapy
Secondary prevention therapy
Which drugs are involved in anti-platelet therapy?
Aspirin
Clopidogrel or Prasugrel or Ticagrelor
What treatment is involved in anti-ischaemic therapy?
Nitrates for pain
What treatment is involved in secondary prevention therapy?
Statins, ACE inhibitors, Beta blockers
Smoking cessation , Lifestyle modification
What is the importance of rapid treatment in STEMI?
Morphine and/or nitrates for pain relief
Antiplatelet agents
Primary angioplasty
thrombolytics
How is an emergency primary angioplasty performed?
in a catheter lab, under local anaesthetic through arteries
take small thin tubes up to the heart under X-ray guidance
inject dye into the arteries
take some pictures to see what’s blocked
angioplasty to reopen the blockage
What are the features of unstable angina?
occurs when the patient is at rest
has a recent onset (less than two months 2 months)
Recent acceleration / progression of angina symptoms
Normal cardiac biomarkers are present (troponin)
What criteria are used to identify high-risk patients?
Elderly, Recurrent chest pain, HF Elevated troponin levels Renal impairment Dynamic ST depression or T wave changes on ECG Haemodynamic instability Major arrhythmias
What is the pathology behind unstable angina?
caused by the dynamic obstruction of the coronary artery due to a plaque rupture with superimposed thrombosis or spasm
Which antiplatelet agents are used to treat NSTEMIs?
aspirin + clopidogrel
What are examples of primary angioplasty treatments used to treat NSTEMIs?
balloons, stents
What is the effect of primary angioplasty treatments when treating NSTEMIs?
the artery is mechanically reopened, restoring blood flow
When are thrombolytics used to treat NSTEMIS?
when there is no access to primary angioplasty
