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MBBS VI - SpC - Medicine > Cardiac - CAD/IHD > Flashcards

Cardiac - CAD/IHD Flashcards

1
Q

Compare stable and unstable angina

A
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2
Q

CAD causes

A
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3
Q

Define risk factors of coronary artery disease

Signs of risk factors

A

□ Modifiable: abdominal obesity, BP, cholesterol, cigarette smoking, alcohol, diet, DM, lack of exercise, cocaine abuse

□ Non-modifiable: family Hx of CVD, male gender, advanced age

Signs:
BP: >15mmHg arm BP disparity

> 30 BMI

Lipid
- Cutaneous xanthomas, xanthelesma, corneal arcus

DM:
- acathosis nigricans, skin tags

Others:
- Franks sing (ear lobe crease)
- Tar stains, teeth stains
- Wheezing, prolonged expiration (COPD)

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4
Q

Stable angina

Clinical presentation

A
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5
Q

Associated non-chest pain manifestations of myocardial ischemia

A

Dyspnea:
rest or exertional
Paroxysmal nocturnal dyspnea

Abdomen:
Atypical, sharp pain
RUQ pain (mimic pancreatitis or gallbladder disease)
Nausea and vomiting

Psychologial:
- Intense Fear

Diaphoresis

Weakness, syncope, coma

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6
Q

Atypical angina features

A
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7
Q

Stable angina

P/E

A
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8
Q

Clinical grading of angina pectoralis

A

CCS grading of angina pectoralis
0 – asymptomatic
I – angina with strenuous exertion
II – angina with moderate exertion
(slight limitation of ordinary activities)
III – angina with mild exertion
(great limitation) → indicated for Tx
IV – angina at rest

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9
Q

Non-invasive assessment of CAD

Indications
Modalities

A

Indications
o Diagnosis of stable ischemic heart disease (NOT for AMI)
o Risk stratification after acute coronary syndrome (ACS)
o Evaluate exercise tolerance
o Localization of ischemia

Investigations:
Blood tests

12-lead ECG, Echocardiogram

CXR

Stress testing
* Exercise tolerance test + ECG/ Imaging
* Pharmacological stress test with Adenosine or Dobutamine

Imaging:
- SPECT scan
- Cardiac MRI
- Multidetector row computed tomography scan (MDCT) for coronary artery calcium (CAC) score
- Coronary CT/ MR angiography (CTA/ MRA)

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10
Q

blood test metrics for suspected coronary artery disease

A

Blood:
* CBC
* Thyroid function test
* Fasting glucose, HbA1c, OGTT > DM
* Fasting lipid profile > Hyperlipidaemia
* RFT/ Creatinine (prognostic)
* LFT, CK (statin)

Markers:
* High-sensitivity C-reactive proteins
* Brain natriuretic peptide (BNP)
* hs- TNT

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11
Q

selection process of diagnostic investigations for suspected coronary artery disease

A

Contraindicated for stress testing / Clinical findings warrant coronary imaging» CT Coronary angiography

No contraindication for stress testing + unable to exercise» Pharmacological stress test

No contraindication for stress test + able to exercise» Exercise stress test

No contraindication for stress test + able to exercise + no previous revascularization/ resting ECG normal» Exercise tolerance test with ECG

2,3,4 may require follow-up coronary imaging if high risk or inadequate information for diagnosis

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12
Q

Exerise stress test

Procedure
Protocol
Target HR
Abnormal results

A
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13
Q

Pharmacological stress test

Indication
Drugs

A
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14
Q

SPECT/ rMPI scan

MoA
Procedure
Evaluated metrics
Abnormal results

A
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15
Q

Cardiac MRI

Indication
Function

A
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16
Q

Multidetector row computed tomography scan (MDCT) for coronary artery calcium (CAC) score

Indication
Function

A
17
Q

CT/ MR coronary angiogram

Indication
Contraindication
Function

A

Direct indications for coronary angiogram
* Unacceptable angina despite medical therapy
* Non-invasive test results with high-risk features
* Angina or risk of CAF with depressed LVEF
* Unclear non-invasive test results and prognosis

18
Q

Invasive coronary angiography

Indications

A
19
Q

CAD

Poor prognostic factors

A
20
Q

Mechanism of silent myocardial ischaemia

A

Long term diabetes
> Reduced nerve growth factor
> failed development of cardiac sensory system
> failed afferent signal to thoracic ganglia and impulse convergence with somatic nerve fibers
> no chest pain

21
Q

Non-cardiac causes of IHD

A

Decrease oxygen delivery - hypoxemia
- Anemia, Sickle cell disease, carbon monoxide poisoning

Endocrine
- Hyperthyroidism (thyrotoxic AF), Pheochromocytoma

22
Q

Stable CAD

Treatment protocol

A

5 principles of management of IHD
* Patient education and decision making
* Manage comorbid conditions
* Aggressive modification of preventable risk factors
* Pharmacological management
* Revascularization surgery: PCI, CABG

23
Q

Coronary revascularization in stable CAD

Indications

A
24
Q

CABG vs PCI

Comparison in outcome

A

Comparison between PCI and CABG
o CABG is superior to PCI in reducing the need for repeat revascularization and increases rate of freedom from angina in patients with severe CAD BUT is associated with a higher risk of stroke
o CABG is preferred over PCI in patients with DM

25
Q

CABG

Approach
Conduits

A
26
Q

Indications for CABG over PCI

A

Two vessel disease and proximal LAD lesion

Triple vessel disease

Unprotected left main coronary artery disease

27
Q

CVD prevention in patients with diagnosed atherosclerotic cardiovascular disease (4)

A

LDL-C >50% reduction and <1.8mmol/L

SBP <140 - 130 mmHg

Antithrombotic therapy

Stop smoking and lifestyle recommendations

28
Q

Outline 6 classes of lipid modifying therapies proven to reduce CVD

A

Statins (1st line, most effective in lowering LDL-C and non-HDL-C)

Cholesterol absorption inhibitors e.g. Ezetimibe (2nd line)

PCSK9 inhibitors (3rd line)

Bile acid sequestrants

Long-chain omega-3 fatty acids

antisense oligonucleotide inhibitor of apolipoprotein B (for familial hypercholesterolemia ONLY)

29
Q

List classes of drugs for prognostic improvement of IHD

A

Antiplatelets/ anticoagulants
Statins/ lipid modifying drugs: in all patients regardless of LDL, first line
± ACEI only in those with HTN, LVEF ≤40%, DM/CKD
± ARB only in those with SIHD, HTN, DM, Poor LVEF and refractory to ACEI

30
Q

Differences and similarities between Amlodipine, Nifedipine, Diltiazem and Verapamil action on heart (different CCBs)

A

Amlodipine and Nifedipine: (for low basal HR)
* Increase HR
* No effects on SA and AV node conduction

Diltiazem and Verapamil: (for tachycardia)
* Decrease HR
* Decrease SA and AV node conduction

ALL:
* Decrease myocardial contractility
* Increase neurohormonal activation
* Increase vascular dilation
* Increase coronary flow

31
Q

Beta-blocker for IHD

Indications
Contraindications
S/E

A

Indication:
* First-line monotherapy or combination with CCB or nitrate to decrease angina
* Systolic LV failure (LVEF < 40%) and past-MI
* Ventricular rate control in A-fib

Side effects:
- Bradycardia, syncope, hypotension, bronchial spasm

Contraindications: (electrical and veqssel problems)
* AV block, sinus node dysfunction
* Bronchial asthma (vasocontriction)
* Vasospasm angina, PAD, Raynaud’s phenomenon
* Depression

32
Q

CCB for IHD

Indications
Contraindications
S/E

A

Indications:
* Monotherapy if refractory/ intolerant to B-blocker
* Combination with B-blocker or nitrates to decrease angina
* Vasospasm angina ** (B-blocker C/O)**
* Ventricular rate control in A-fib

Side effects:
* Bradycardia (non-DHP CCBs)
* syncope, hypotension, peripheral edema, headache, dizziness, constipation

C/O:
AV block, Heart failure, sinus node dysfunction

33
Q

Nitrate for IHD

Indications
Contraindications
S/E

A

Indication:
* Relieve acute anginal pain
* Prophylaxis to increase exercise tolerance and prevent exercise-induced ischaemia
* Long-acting nitrate to decrease angina

Side effects:
- Hypotension, syncope, tachycardia, headache

C/O:
* HOCM
* Same-day use with Selective Phosphodiesterase Inhibitors (PDE-5) e.g. Sildenafil
* SBP <90mmHg/ Severe hypotension

34
Q

List 4 novel agents for use in IHD

A

Ivabradine (funny current blocker, decrease HR and myocardial oxygen consumption)

Ranolazine (reduce Ca overload, anti-arrhythmic)

Trimetazidine (Increase energy for myocardial contraction)

Nicorandil (dilation of coronary resistance arterioles and vasodilation)

MBBS VI - SpC - Medicine (80 decks)

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