Valvular Heart Disease, Ischaemic heart disease

Question 1

What is the Framingham Heart Study

Answer 1

• where ‘risk factors’ was first coined

Question 2

what are Controllable risk factors of CHD

Answer 2

• high cholesterol and high BP - smoking link - obesity and inactivity link - diabetes link

Question 3

what are non-controllable factors of CHD

Answer 3

• age - family Hx - previous heart attack

Question 4

Why does Ischaemic heart disease occur ?

Answer 4

• artherosclerotic plaque build up within one or more coronary arteries - obstructing myocardial blood flow

Question 5

What are some clinical manifestations of Ischaemic heart disease

Answer 5

• asymptomatic stable angina - Acute coronary syndromes - long- term manifestations heart failure arrhythmia sudden death

Question 6

What are acute coronary syndromes of IHD

Answer 6

• unstable angina - NSTEMI - STEMI

Question 7

What is the pathology of Stable Angina?

Answer 7

• Ischaemia due to fixed athermatous stenosis of one or more coronary artery

Question 8

What is the pathology and presentation of Unstable Angina?

Answer 8

• this is Ischemia caused by dynamic obstruction of a coronary artery due to plaque rupture with superimposed thrmobosis and spasm
• occuring with increasing frequency and severity
• occuring at rest or more frequently at night
• not relieved quickly with nitroglycerin
• usually assocaited with ST depressin on the ECG

Question 9

What is the pathology of myocardial infarction?

Answer 9

• Myocardial necrosis caused by acute occlusion of coronary srtery due to plaque rupture and thrombosis

Question 10

What is the pathology of heart failure?

Answer 10

• Myocardial dysfunction dur to infarction or ischaemia

Question 11

What is the pathology of arrhythmia?

Answer 11

• Altered conduction due to ischaemia or infarction

Question 12

What is the pathology of sudden death?

Answer 12

• Ventricular arrhytmia,
• asystole or
• massive myocardial infarction

Question 13

What is classified as typical stable Angina?

Answer 13

• substernal chest pain discomfort - provoked by exertion or emotional stress - relieved by rest and or nitrates within minutes

Question 14

How is Stable Angina initially treated?

Answer 14

1st line treatment

• short acting nitrates alongside
• Beta-blockers or CCB-heart rate
• consider CCB-DHP if low heart rate or if there are contraindications

2nd line treatment ( add or sitch some 1st line treatments)

• Ivavradine
• Long-acting nitrates
• Nicorandil

Question 15

Other treatments of angina

Answer 15

• lifestyle management
• control of risk factors
• educating the patient
• aspirin, statins
• consider ACE-Inhibitors or ARBs (angiotensin receptor blockers)

Question 16

What are acute coronary syndromes ACS?

Answer 16

Unstable anginga

• Tropinin levels are not elevated in unstable angina

Acute myocardial infarction

• rise in the cardiac enzyme troponin seen in blood tests
• Troponin relased into the blood stream following injury of the heart muscle

Question 17

What is the pathology and presentation of UA/NSTEMI ?

Answer 17

• ST depression on an ECG or T wave inversion
• enzyme or troponin elevation
• is an incomplete and small infarct
• occurs early n the cours of a Q-wave infarct, before the vessel is totally occluded

Question 18

What is the pathology of STEMI ?

Answer 18

• generally refers to complete occlusion of the coronary vessels: seen as St elevation on ECG
• Incomplete occlusion of the coronary vessel is associated with ST depression

Question 19

What are some symptoms of ACS?

Answer 19

• discomfort/ pain in the centre of the chest that lasts more than a few minutes or recurs - discomfort/pain radiating to other areas - can occur at rest as well as at exertion - not relieved immediately with sublingual GTN

Question 20

What is sublingual GTN

Answer 20

• glyceryl trinitrate, taken underneath the tongue

Question 21

In order of importance

What should be considered during the immediate assessment of patients suspected of ACS?

Answer 21

• Patient History
• ECG
• Physical examination
• Risk stratification
• cardiac biomarkers

Question 22

What is the medical management of ACS?

Answer 22

• Antiplatelet therapy:
• Anti-ischaemic therapy
• Secondary prevention therapy

Question 23

What antiplatelet therapy is given to ACS patient?

Answer 23

• aspirin
• clopidogrel/ prasugrel/ ticagrelor

Question 24

What anti-ischamic therapy is given to ACS patient?

Answer 24

• nitrates

Question 25

What secondary prevention therapy is given to ACS patient?

Answer 25

• Statins
• ACE inhibitors
• Beta-Blockers
• Smoking cessation/ lifestyle modification

Question 26

What is the treatment of a STEMI

Answer 26

• Morphine and/or nitrates for pain relief
• Antiplatelet agents (aspirin + clopidogrel)
• Primary Angioplasty: artery is mechanically reopened
• Thrombolysis drugs

Question 27

What are symptoms/ definitions of unstable Angina

Answer 27

• Angina at rest >20mins
• New onset (< 2 months) exertional angina
• recent (<2 months) acceleration or progression of angina symptoms
• normal cardiac biomarker

Question 28

What is an NSTEMI?

Answer 28

• the absence of ST elevation on ECG but with angina symptoms and elevated cardiac biomarkers

Question 29

What else could cause a positive troponin

Answer 29

• pneumonia - pulmonary embolism - pericarditis -sepsis - heart failure - uncontrolled tachyarrhythmia

Question 30

What makes a person high risk for ACS?

Answer 30

• elevated troponin levels
• renal impairment
• recurrent chest pain
• Dynamic ST depression or T wave change on ECG
• Haemodynamic instability
• Major arrhythmias
• Heart failure
• Elderly

Question 31

How is UA/NSTEMI managed

Answer 31

• Pain relief (analgesia)
• Antiplatelt therpay
• antiischameia therapy
• Statins
• Early coronary angiography with a view to revascularize (stenting or CABG)