Valvular Heart Disease, Ischaemic heart disease Flashcards
What is the Framingham Heart Study
- where ‘risk factors’ was first coined
what are Controllable risk factors of CHD
- high cholesterol and high BP - smoking link - obesity and inactivity link - diabetes link
what are non-controllable factors of CHD
- age - family Hx - previous heart attack
Why does Ischaemic heart disease occur ?
- artherosclerotic plaque build up within one or more coronary arteries - obstructing myocardial blood flow
What are some clinical manifestations of Ischaemic heart disease
- asymptomatic stable angina - Acute coronary syndromes - long- term manifestations heart failure arrhythmia sudden death
What are acute coronary syndromes of IHD
- unstable angina - NSTEMI - STEMI
What is the pathology of Stable Angina?
- Ischaemia due to fixed athermatous stenosis of one or more coronary artery
What is the pathology and presentation of Unstable Angina?
- 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
What is the pathology of myocardial infarction?
- Myocardial necrosis caused by acute occlusion of coronary srtery due to plaque rupture and thrombosis
What is the pathology of heart failure?
- Myocardial dysfunction dur to infarction or ischaemia
What is the pathology of arrhythmia?
- Altered conduction due to ischaemia or infarction
What is the pathology of sudden death?
- Ventricular arrhytmia,
- asystole or
- massive myocardial infarction
What is classified as typical stable Angina?
- substernal chest pain discomfort - provoked by exertion or emotional stress - relieved by rest and or nitrates within minutes
How is Stable Angina initially treated?
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
Other treatments of angina
- lifestyle management
- control of risk factors
- educating the patient
- aspirin, statins
- consider ACE-Inhibitors or ARBs (angiotensin receptor blockers)
What are acute coronary syndromes ACS?
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
What is the pathology and presentation of UA/NSTEMI ?
- 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
What is the pathology of STEMI ?
- 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
What are some symptoms of ACS?
- 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
What is sublingual GTN
- glyceryl trinitrate, taken underneath the tongue
In order of importance
What should be considered during the immediate assessment of patients suspected of ACS?
- Patient History
- ECG
- Physical examination
- Risk stratification
- cardiac biomarkers
What is the medical management of ACS?
- Antiplatelet therapy:
- Anti-ischaemic therapy
- Secondary prevention therapy
What antiplatelet therapy is given to ACS patient?
- aspirin
- clopidogrel/ prasugrel/ ticagrelor
What anti-ischamic therapy is given to ACS patient?
- nitrates
What secondary prevention therapy is given to ACS patient?
- Statins
- ACE inhibitors
- Beta-Blockers
- Smoking cessation/ lifestyle modification
What is the treatment of a STEMI
- Morphine and/or nitrates for pain relief
- Antiplatelet agents (aspirin + clopidogrel)
- Primary Angioplasty: artery is mechanically reopened
- Thrombolysis drugs
What are symptoms/ definitions of unstable Angina
- Angina at rest >20mins
- New onset (< 2 months) exertional angina
- recent (<2 months) acceleration or progression of angina symptoms
- normal cardiac biomarker
What is an NSTEMI?
- the absence of ST elevation on ECG but with angina symptoms and elevated cardiac biomarkers
What else could cause a positive troponin
- pneumonia - pulmonary embolism - pericarditis -sepsis - heart failure - uncontrolled tachyarrhythmia
What makes a person high risk for ACS?
- elevated troponin levels
- renal impairment
- recurrent chest pain
- Dynamic ST depression or T wave change on ECG
- Haemodynamic instability
- Major arrhythmias
- Heart failure
- Elderly
How is UA/NSTEMI managed
- Pain relief (analgesia)
- Antiplatelt therpay
- antiischameia therapy
- Statins
- Early coronary angiography with a view to revascularize (stenting or CABG)
