Management of CAD Flashcards
1
Q
what is angina?
A
insufficient oxygen delivery to heart muscle leading to ischaemia
2
Q
in 2014, CAD was the single most common cause of death, what was the percentage?
A
27%
3
Q
how many people in the UK have CHD, what is the cost yearly for this?
A
2.3 million costing £9 billion yearly
4
Q
in the UK, how many admissions are as a result of MI?
A
100,000
5
Q
what is the pathology of angina?
A
- Coronary plaque causes decrease in perfusion pressure, decrease in arterial oxygen content
- Compensates – increase in Hr, preload, afterload, contractibility
6
Q
describe stable angina?
A
- Predictable – exertion, exercise, extremes of temp (vasoconstriction)
- Relieved by rest/ nitrates
- Long term management prevent attacks coming on and reducing risk of CAD
7
Q
describe unstable angina?
A
- Sudden deterioration in angina symptoms – no ECG changes, no troponin rise
- Result of atheromatous plaque rupture
- Lasts longer and unresponsive
- Symptoms control prevention of progression to an MI
8
Q
what is acute coronary syndromes?
A
spectrum of conditions such as unstable angina/ NSTEMI and STEMI
9
Q
what is troponin?
A
protein released when cardiac muscle is damaged - not normally present in bloods
10
Q
what is the pathophysiology in a STEMI MI?
A
- Plaque ruptures leading to thrombosis
- Fully occluded lumen
- MI with irreversible necrosis of the heat can lead to long term complications
11
Q
what is the pathophysiology in a NSTEMI MI?
A
- partially blocked lumen eg atherosclerosis
Myocardial necrosis is evident – risk of progressing to a STEMI - Symptomatic relief of ischaemia prevents further MI and death
12
Q
name a nitrate used to treat angina and acute heart failure?
A
glycerol trinitite - GTN spray
13
Q
what is the action of GTN spray?
A
- Action – vasodilating improving coronary blood flow
- Decrease after/ pre load
- Decrease myocardial workload
- Decrease oxygen demand
14
Q
what are the side effects of GTN spray?
A
headache (means it working as its sublingual), hypotension, syncope (dizziness – take while sat down), facial flushing
15
Q
what is contra-indicated with GTN spray?
A
acute circulatory failure, shock, head trauma, severe hypotension, aortic stenosis (likely to cause further syncope)
16
Q
how many hours free of nitrate do you need a day?
A
12hrs
17
Q
in relation to GTN spray when should an ambulance be called?
A
If no relief after 5 mins of taking spray, repeat if no relief again after 5 mins, call an ambulance
18
Q
name some anti-platelet drugs?
A
aspirin, ticagrelor, clopidogrel, plasugrel
19
Q
what is the action of antiplatelets?
A
reduces blood viscosity, disrupts platelet activation including inhibition of platelet agonists, adhesion or aggregation
20
Q
when are anti-platelets used?
A
revascularisation to restore sufficient blood flow to affected vessel (reperfusion)
- Inhibit clot formation
- Support plaque stabilisation: no thrombus
- Secondary prevention of CV disease, TIA, stroke by aspirin
21
Q
what are the side effects of antiplatelets?
A
bronchospasm, GI bleeds (blood not sticking together), GI irritation (aspirin), tinnitus
22
Q
what are contra-indicated with anti-platelets?
A
bleeding risk, low platelet count, allergy
23
Q
what is the normal dose of aspirin? (anti-platelet)
A
300mg loading, low dose is 75mg
24
Q
what is the normal dose of ticagrelor? (anti-platelet)
A
180mg loading then 90mg BD
25
what is the normal dose of prasugrel? (anti-platelet)
60mg STAT, then 10/5mg daily while awaiting PCI
26
name some glycoprotein IIb/IIa antagonists?
abicicimab, eptifbratide, tiofibran
27
what is the action of glycoprotein IIa/ IIb antagonists?
inhibit final pathway involved in platelet aggregation
inhibits fibrogen binding
28
what is the action of glycoprotein IIa/ IIb antagonists?
inhibit final pathway involved in platelet aggregation
inhibits fibrogen binding
29
when is glycoprotein IIb/IIa used?
prevention of ischaemic cardiac complications in those undergoing PCI
- Short term prevention of MI in those with unstable angina and waiting for PCI
30
what are the side effects of glycoprotein IIb/IIa antagonists?
bleeding, back pain, fever, headaches, hypotension, nausea
31
what are contra-indicated with glycoprotein IIb/IIa antagonists?
active internal bleeding, hypertensive retinopathy, major surgery in last 2 months
32
name anticoagulants
heparin
33
what is the action of heparin?
prevents blood from clotting by suppressing synthesis or function of various clotting factors
anti-thrombotic
does not thin blood
34
what are types of heparin?
low molecular - enoxaparin, daltaparin, tinzaparin (TED)
unfractionated - non seperated
fondaparinux - synthetic heparin
35
what is the dosage of nicrorandil?
one tablet 10/20mg BD
36
what is the action of nicrorandil?
nitrate like action (vasodilator), K+ channel opener - increase blood flow due to less resistance
37
when is nicrorandil used?
prevention and long term management of angina
38
what are the side effects of nicrorandil?
headaches, ulceration, dizziness, flushing
39
what is contra-indicated of nicrorandil?
severe hypotension, LV failure, hypovolaemia, acute pulmonary oedema
40
what is the action of ranolazine?
facilitates myocardial relaxation, reduces flow of Ca2+
does not affect heart rate
41
when is ranolazine used?
as an adjunct in stable angina
42
what are the side effects of nicrorandil?
dizziness, headache, constipation, nausea, vomiting
43
what is the action of ivabradine?
lowers heart rate by acting on sinus node
- Decreased myocardial oxygen demands
- No effect on BP/ contraction
44
when is ivabradine used?
treatment of angina in patients with normal sinus rhythm
45
what are the side effects of ivabradine?
GI disturbances, nausea, constipation, diarrhoea
46
what is contra-indicated in ivabradine?
heart rate <75, acute MI, unstable angina, unstable heart failure
47
what is the action of statins?
stabilising plaques by HMG-CoA reductase inhibitors
block enzyme involved in cholesterol synthesis
48
when are statins used?
primary (reduce hypercholestrolaemia/ hypertension) or secondary prevention of CV events
49
what are the common side effects of statins?
muscle aches and pains
myopathy - rhabdomolysis - muscle tissue releases proteins and electrolytes into blood which can cause permanemt disability/ fatal
nausea, insomnia, vivid dreams
50
what is contra-indicated with statins?
liver disease
51
what is the function of reperfusion therapy?
to restore blood stores - posterior MI/ left bundle branch block
52
what is PCI?
percutaneous coronary intervention - opens up blocked artery
53
how does PCI work?
balloon/ stent in artery to open it uo
used with drug eluting stent
54
what are drug eluting stents?
slow release medication to prevent clots around stents
55
what better thrombolytics or PCI?
PCI -less bleeding, mortality, risk of stroke, re-infarction, infarct angina
56
name some thrombolytic drugs
streptokinase, tenecteplase, altepase
57
when do thrombolytic drugs need to be used?
within 6-12 hrs of first symptoms
58
how do thrombolytic drugs work?
fibrinolytic drug activate plasminogen which turns into plasmin which then degrades the clot, breaking up thrombus
59
when are thrombolytic drugs used?
acute MI, PE, ischaemic stroke
60
what are the side effects of thrombolytics?
risk of cerebral bleed
61
Name at least 5 absolute contra-indications of thrombolytics
haemorrhagic stroke/ stroke at any time. Ischaemic stroke in last 6 months, CNS damage, recent trauma/ surgery, bleed. GI bleeding in last month, known bledding disorders, aortic dissection
62
what are relative contra-indications of thrombolytics?
TIA in last 6 mths, dementia, oral anticoagulant drugs, pregnancy within 1 week post-patrum, non compressible punctures, traumatic resuscitation, refractory hypertension, advanced liver disease, ineffective endocarditis, active peptic ulcer
63
what is lifestyle advice of CAD?
ineffective endocarditis, active peptic ulcer
Lifestyle:
* Low dose aspirin – decrease death by 25%
* Statins
* Smoking
* Diet and weight modifications
* DVLA needs informing
* Limit alcohol – less than 14 units a week
* Increased exercise
* Control diabetes, hypetension
64
what are the secondary medical management 6As?
for CAD
Aspirin – 75mg once a day
Another antiplatelet – eg clopidogrel or tricagrelor (those after PCI, low risk of bleeding)
Atorvastatin – 80mg once a day
ACEi – ramipril titrated as tolerated to 10mg a day
Atenolol- or any beta blocker as high as tolerated
Aldosterone antagonist- for those with heart failure (eplerenone titrated to 50mg once daily)
65
what are the NICE guidelines for stable angina?
- First line – beta blocker/ CCB
- If symptoms not controlled- consider switching or using combination (DO NOT USE B BLOCKER WITH VERAPAMIL/ DILTIAZEM)
- Third line – long acting nitrate, ivabradine, ranolazine
- If patient can not tolerate CCB/ b blocker then monotherapy or nitrate/ ivabradine/ ranolazine
- Triple therapy while awaiting PCI
66
in those aged 75+ and awaiting PCI which dual anti-platelet combination is best?
aspirin with ticagrelor/ clopidogrel
67
what is the management of NSTEMI/ unstable angina?
B- beta blockers
A- anti-platelet - aspirin
T- sTaTins
M - morphine
A- another antiplatelet ( ticagrelor/ clopidogrel)
N - nitrates - GTN spray
give oxygen if needed
68
define myocardial infarction
necrosis of myocardial tissue following occlusion of coronary artery and subsequent ischaemia
MI is a major manifestation of CAD
69
what type of pain is associated with MI?
sudden onset, substernal, crushing, tightness, severe, unrelieved by GTN, may radiate to jaw, shoulder, neck, back
70
what are normal symptoms of MI?
dyspnea, syncope, nausea, vomiting, extreme weakness, diaphoresis, denial, increase in Hr
71
what is initial MI treatment?
- Pain relief and antiplatelets: diamorphine, morphine, oxygen, sublingual GTN or IV, aspirin, cyclizine or metoclopramide
- Thrombolysis – with or without heparin
- IV beta blockers, IV nitrates
- Asprin, ACEi, oral B blockers, lipid lowering agents, dual antiplatelets
- Angiography as needed
- Revascularization as needed
72
what is initial MI treatment?
B- b, blockers
A- antiplatelets (dual)
T- thrombolytics
M- morphine
A- aspirin, ACEi
N- nitrates- GTN spray
Give oxygen as needed
73
what is the role of cardiac rehabilitation?
motivates patients with similar conditions but individually meets everyone's needs - works around medication and exercise capabilities
74
who and when should patients get cardiac rehab?
all people regardless of age and should start sessions within 10 days of being discharged
75
can stenting help restonosis?
30% less restonosis
76
what drugs help manage stable angina?
GTN, ivabradine, ranolazine, nicrovandril, antiplatelets (aspirin + clopidogrel/ tricagrel)
2nd prevention drugs
77
what drugs help manage NSTEMI? unstable angina?
antiplatelet (aspirin + clopidogrel/ tricagelor)
PCI route - prasugrel, unfractionated heparin
drug eluting stent
2nd prevention drug
78
what drugs help manage STEMI?
antiplatelet (aspirin + tricagrelor/ clopidogrel)
PCI route - unfrectionated heparin + parasugrel
drug eluting stent
fibrinolysis route - altepase/ streptokinase/ tenactapase
2nd prevention drugs
79
when giving another antiplatelet, when is each of them work best (clopidogrel, tricagelor, prasugrel)
prasugrel - when undergoing PCI
clopidogrel - if high bleeding risk
tricagelor - any other time
80
other than NSTEMI, what else can increase troponin levels?
CKD, sepsis, myocarditis, aortic dissection, PE
