S8) Ischaemic Heart Disease Flashcards by LUSUMA ACADEMIC OFFICER

Outline, in detail, the principles of history-taking

- Site: location of the pain and if it radiates

- Quality: how the pain feels (sharp, dull, etc)

- Intensity: severity score

- Timing: when it started (sudden/gradual onset)

- Aggravating factors: what makes pain worse?

- Relieving factors: what makes the pain better?

- Secondary symptoms: other symptoms

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What are the two types of chest pain?

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Describe the features of visceral pain

Cardiac ischaemic pain:

Dull, poorly localised
Worsened with exertion

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Describe the features of somatic pain

Pleural/pericardial pain:

Sharp pain, often well localised
Worse with inspiration, coughing or positional movement

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What are the different causes of chest pain?

Cardiac causes – ischaemia, infarction, inflammation (pericarditis)
Non-cardiac causes – upper GI, respiratory, MSK

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What are the respiratory causes of chest pain?

Pneumonia
Pulmonary embolism
Pleurisy

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What are the upper gastro-intestinal causes of chest pain?

Reflux
Peptic ulcer disease

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What are the musculoskeletal causes of chest pain?

Rib fracture
Costochondritis (inflammation of the costal cartilages)

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What is pericarditis?

Pericarditis is the inflammation of the pericardium often secondary to a viral illness
It commonly occurs in men and adults

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How does the pain in pericarditis present?

Retrosternal, sharp
Localised to front of chest
Aggravated with inspiration, coughing, lying flat
Relieved with sitting up and leaning forward

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What can be heard on the examination of pericarditis?

Pericardial rub may be heard on auscultation

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Briefly, explain what cardiac ischaemic chest pain is and how it is managed

Pain secondary to pathology involving the heart (ischaemic heart disease)
Primary concern is to rule out urgent, potentially life-threatening causes of chest pain

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When does heart tissue ischaemia occur?

Heart tissue ischaemia occurs only when metabolic demands of cardiac muscle are greater than what can be delivered via coronary arteries

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Describe the pathophysiology of ischaemic heart disease

Ischaemic heart disease is a disease of the coronary arteries
Fatty deposits build up over time → lipid-laden core with a fibrous external cap (atherosclerosis)

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Risk factors for atherosclerosis are the same as risk factors for ischaemic heart disease.

Identify 6 modifiable risk factors

Smoking
Hypertension
Hypercholesterolaemia
Diabetes
Obesity
Sedentary lifestyle

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Risk factors for atherosclerosis are the same as risk factors for ischaemic heart disease.

Identify 3 non-modifiable risk factors

Age – advanced
Genetics – family history
Gender – males

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In stable angina, the atherosclerotic plaque is ‘stable’.

Describe the clinical features

Dull, retrosternal chest pain
Triggered by exertion
Relieved completely by rest

What are some causes of stable angina?

Coronary artery stenosis
Spasm
Anaemia
Severe aortic valve stenosis

What are the investigations for stable angina?

Bloods: FBC, cholesterol, renal and thyroid function
ECG: rhythm disturbance, atrial fibrillation, pathological Q waves
Chest X Ray

What can be used to treat stable angina?

GTN spray – relieve pains

How does unstable angina differ from stable angina?

Pain occurs at rest
Pain may be more intense
Pain may last longer
Risk of deteriorating further (NSTEMI/STEMI)

What is the cause of unstable angina?

Coronary plaque rupture

Describe the signs and symptoms of a myocardial infarction

Dull, retrosternal chest pain
Radiates to neck & shoulders
Severe chest pain at rest
Look unwell (sweaty, pallor)
Nausea
Dyspnoea

How do you account for the pallor, nausea and vomiting that is accompanied with MI?

Increased autonomic output – SNS reduces functions of all non-essential parts of the body (immunity, GI)
Pain creates substance P which acts on vomiting centres in the brain

What causes myocardial infarction?

**Coronary Heart Disease** is the leading cause of heart attacks

What is Coronary Heart Disease?

**CHD** is a condition in which atherosclerotic plaques accumulate in the coronary arteries

In 3 steps, explain how CHD leads to an MI

⇒ Atherosclerotic plaque ruptures ⇒ Blood clot develops at the site of the rupture ⇒ Clot block blood supply to heart, triggering a heart attack

What is an acute coronary syndrome?

- An **acute coronary syndrome** is a condition wherein acute myocardial ischaemia occurs due to atherosclerotic coronary artery disease - Atheromatous plaques rupture with thrombus formation causing an acute increased occlusion leading to ischaemia

Identify some conditions which are considered as acute coronary syndromes

- Unstable angina - Myocardial infarction - NSTEMI - STEMI

In 3 steps, explain how acute coronary syndromes involve a spectrum of increased occlusion following a plaque rupture

⇒ Atherosclerotic plaque **rupture** ⇒ Platelet aggregation and formation of **thrombus** ⇒ **Partially occlusive** thrombus → **completely occlusive** thrombus

Differentiate between ischaemia and infarction

- **Heart tissue ischaemia**: reduced O₂ supply without enzyme leak - **Heart tissue infarction**: cardiac enzymes leak from necrosed cardiac muscle cells

Differentiate between the clinical examination findings of stable angina and acute coronary syndromes

- **Stable angina:** normal clinical examination (chest pain free at rest) - **Acute coronary syndromes**: normal clinical examination but may appear sweaty, anxious, pale ± clinical signs secondary to complications of cardiac tissue death

Identify and describe the investigations used in the diagnosis of MI

- **ECG** – ST segments, T waves, ± pathological Q wave - **Blood** **tests** – Troponin - **Other investigations** – to exclude potential diagnoses & identify potential complications

Describe the ECG changes in STEMI

**Patterns of infarct:** - ST segment elevation - Hyperacute T waves

Describe the ECG changes in Unstable angina and NSTEMI

**Patterns of ischaemia:** - ST segment depression - T wave flattening or inversion

How does one differentiate between NSTEMI and Unstable angina?

**Blood tests** – there is troponin release in NSTEMI due to cardiac myocyte death

Describe the clinical use of Troponin

- **Troponin** is a biomarker of myocardial damage - However, it released in almost any condition (specificity poor)

Which cardiac conditions result in the release of Troponin?

- Acute coronary occlusion / severe stenosis - Acute heart failure - Prolonged tachycardia - Cardiac trauma

Which non-cardiac conditions call for the release of troponin?

- Acute PE - Pulmonary hypertension - Severe anaemia - Rhabdomyolysis - Kidney failure

Describe the pharmacological management of stable & unstable angina

- **Aspirin** – prevent heart attack, prevent blood clots - **Beta blocker** – reduces blood pressure and slows heart rate - **Statin** – reduce LDL cholesterol - **ACE inhibitor** – lower BP - **Oral nitrate** – ease angina pains, includes GTN (stable angina only)

Identify two surgical interventions in the management of stable & unstable angina

**Repercussion:** - Percutaneous coronary intervention - Coronary artery bypass graft

Describe the general management of myocardial Infarction

- Oxygen - Pain relief - GTN spray (sublingual) - Aspirin - Repercussion (PCI & CABG)