management of CAD Flashcards
what is blue baby syndrome?
Cyanotic heart defect - a congenital defect that occurs due to deoxygenated blood bypassing the lungs and entering the systemic circulation, or a mixture of oxygenated and unoxygenated blood entering the systemic circulation
what occurs in acute (unstable) coronary artery disease
the plaque ruptures, causing (near) total occlusion of the artery due to thrombosis
aims of stable angina treatment
symptoms relief; prognostic benefit
types of treatment for stable angina (3)
lifestyle changes; drugs; revascularisation
what kind of drugs are given to treat stable angina
symptoms: beta blockers, nitrates;
prognosis: satins, aspirin, beta blockers, ACE inhibitors
supply causes of angina (3)
coronary stenosis; anaemia; lung problems
demand causes of angina (5)
tachycardia; preload (venous return); afterload (blood pressure); muscle mass (e.g. hypertrophy); muscle contractility
angina treatment plan
first line - beta blockers (aim for resting HR of 50/60);
add long acting oral nitrates e.g. isosorbide;
Ca2+ channel blockers if B blockers are contraindicated;
referral for coronary angiography;
revascularisation if not controlled by 2 drugs
ESC steps for initial diagnostic management of patients (6)
- assess symptoms and perform clinical investigations
- consider comorbidities and QoL (revascularisation futile?)
- resting ECG, biochem, CXR, echo etc. (check LEVF)
- assess pre-test probability and clinical likelihood of CAD (other causes for chest pain?)
- offer diagnostic testing e.g. coronary angiogram, invasive angiography etc.
- choose appropriate therapy based on symptoms and event risk
examples of investigations that can be done (6)
exercise stress test; MIBI; CT coronary angiography; stress MRI; dobutamine stress echo; coronary angiogram (most used)
when is a coronary CTA indicated
low clinical likelihood of CAD; local expertise/availability; patient characteristics indicate high quality image; info on atherosclerosis needed; no history of CAD
when is non-invasive testing for ischaemia indicated
high clinical likelihood; revascularisation likely; local expertise/availability; visibility assessment also required
when is invasive coronary angiography indicated
high clinical likelihood and sever symptoms refractory to medical therapy; typical angina at low level of exercise; clinical eval indicates high risk of events; LV dysfunction suggestive of CAD
what is the difference between ad coronary CTA and invasive coronary angiography
invasive angiogram involves a catheter being inserted into the artery and to the area being studied while a CT angiogram does not require the insertion of a catheter
what is a PCI
percutaneous coronary intervention - a non-surgical procedure that uses a catheter to place a stent to open up blood vessels in the heart
when is PCI indicated
ACS - STEMI, NSTEMI;
stable angina - symptoms despite 2 anti anginals, less complex disease
what is CABG
coronary artery bypass grafting - the blood vessels that are used are typically the saphenous vein, internal mammary artery or the radial artery (look for these scars!)
indications for CABG (3)
left main stem disease; left main stem equivalent disease; proximal 3 vessel disease
PCI vs CABG (risk, suitable anatomy, complex disease, repeat vascularisation)
PCI: low risk, 1,2,3 vessel/LMS disease suitable, less advisable if SYNTAX >22, 25% revasc at 5 years;
CABG: 3% risk, usually LMS/3 vessel disease, preferred option for high score, 13% revascularisation at 5 years
what scoring system is used for CAD disease complexity
SYNTAX
STEMI vs NSTEMI/UA thrombus
STEMI - total occlusion; NSTEMI - unstable clot, not totally occluded
STEMI treatment pathway
chest pain —-> ambulance –(aspirin 300mg, ticagrelor)–> hospital –(heparin + GpIIb/IIIa inhibitor if PPCI NOT indicated, if indicated don’t give)–>PPCI if <4hrs, otherwise fibrinolysis if <12hrs, give antithrombin at the same time —-> give prusagrel with aspirin (if not already on anticoag or >75yro, in this case give clopi) —-> offer stenting with drug-eluding stent if appropriate –(ACEi, BB, statin, continue aspirin)–> home
if unsuitable for either (i.e. >12hrs then medical management, give aspirin + ticagrelor)
NSTEMI treatment pathway
chest pain -> ECG/troponin -> rule out ST elevation -> risk assessment -> dula antiplatelet, anticoag, BB, statin -> refer for PCI/angio or medical treatment -> lifestyle changes + aspirin, ticagrelor (12mo), statin, BB, ACEi/ARB
STEMI mimics on ECG (5)
LBBB; ST elevation due to early repolarisation, often seen in younger pts; migraine; LOC; stroke
what can be used to see if a STEMI is occuring in a pt w LBBB
Sgarbossa criteria:
Concordant ST elevation ≥ 1 mm in ≥ 1 lead
Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave
maximum time for STEMI diagnosis to treatment for PCI to be chosen
120mins
secondary prevention for ACS
- ACEi (indefinitely)
- dual anti platelet therapy (12 months) - unless anti-coag is indicated (see 5.)
- BB (indefinitely if reduced EF, otherwise for 12mo)
- statins (indefinitely)
- check for indications of anti-coag (give DOAC +clopi for PCI and aspirin if no PCI)
universal classification of MI (5)
- Spontaneous myocardial infarction related to atherosclerotic plaque rupture;
- Myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand;
- MI resulting in death when biomarker values are unavailable;
4a. MI related to PCI; 4b. MI related to stent thrombosis; - MI related to CABG
universal classification of MI (5)
- Spontaneous myocardial infarction related to atherosclerotic plaque rupture;
- Myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand;
- MI resulting in death when biomarker values are unavailable;
4a. MI related to PCI; 4b. MI related to stent thrombosis; - MI related to CABG
