Cardiology: Ischaemic Heart Disease I

Question 1

How does angina typically present? [4]

Answer 1

Chest pain:
- Left sided
- Tight / squeezing
- Pressure like pain
- Associated SOB
- Radiates down left arm or back

Pain worse with exercise or cold weather

Pain relieved with rest

Pain relieved with GTN

Question 2

Describe what is meant by cresendo angina [1]

Describe the clinical consequence of this [1]

Answer 2

Recent progressive drop in exercise tolerance

Suggests narrowing is getting tighter and vulnerable atherosclerotic plaque may occur

If pain at rest: unstable angina

Question 3

NICE define anginal pain as what? [3]

Answer 3

NICE definition:
1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes

Interpretation:
* Patients with all 3 features have typical angina
* Patients with 2 of the above features have atypical angina
* Patients with 1 or none of the above features have non-anginal chest pain

Question 4

How long does it take for GTN to provide symptomatic relief of angina? [1]

Answer 4

~ 2mins

If more: then not GTN

Question 5

What are the different causes of angina? [3]

Answer 5

Coronary Atherosclerosis
- Predominant cause

Also:
Coronary artery vasospasm:
- Constriction of the coronary arteries, leading to transient ischemia.

Microvascular dysfunction:
- Impaired function of the coronary microvasculature, leading to inadequate blood supply to the myocardium.

Extracoronary factors: which increase myocardial oxygen demand or decrease supply.
- Aortic stenosis
- Aortic regurgitation
- hypertrophic cardiomyopathy
- significant anemia

Question 6

Why does AS and AR cause angina? [1]

Answer 6

Coronary arteries emerge just above the aortic valve: so get impeded blood flow

Question 7

What is the name of this sign when asked for description of chest pain? [1]

Answer 7

Levine’s sign

Question 8

What is decubitus angina? [1]

Answer 8

Form of stable angina where get pain when lying down without any apparent cause

Question 9

What is meant by Prinzmetal’s or variant angina? [1]

Answer 9

When you get transient ST elevation due to coronary vasopasm (artery isn’t blocked, but muscle is in spasm)

Question 10

What is meant by cardiac syndrome X? [1]

Answer 10

St depression on excerise ECG but normal angiogram

Sign of microvascular angina

Question 11

What is meant by St Vincent’s angina? [1]

Answer 11

Not actually angina: pharyngitis due to ulcerative ginigivitis

Question 12

What is the name for this sign of hyperlipdaemia? [1]

Answer 12

corneal arcus lipid deposits that appear as rings on the outer region of the cornea

Question 13

NICE:
What investigations are used to investigate angina? [3]

Answer 13

1st line:
- CTCA (+calcium score)

2nd line:
- Non-invasive functional imaging (looking for reversible myocardial ischaemia)

3rd line:
- Invasive coronary angiography

Question 14

Describe how invasive coronary angiography occurs [3]

Answer 14

A catheter is inserted into the patient’s brachial or femoral artery

Directed through the arterial system to the aorta and the coronary arteries under x-ray guidance

Contrast is injected to visualise the coronary arteries and identify any areas of stenosis using x-ray images

This is considered the gold standard for determining coronary artery disease

Question 15

What function investigations can you conduct for borderline cases of angina / need further investigations? [4]

Answer 15

• Exercise or stress ECHO
• Nuclear medicine: myocardial perfusion scan
  scans use a small amount of radioactive substance to create images which show blood flow to the heart muscle
• Cardiac MRI with stress perfusion
• Exercise ECG

Question 16

What advice do you give when giving GTN spray? [1]

Why? [1]

Answer 16

Can cause dizziness: due to veno-dilatation and BP to drop

Question 17

All patients with angina should be prescirbed which drugs? [2]

Answer 17

Aspirin 75mg (prevent risk of MI)

Statin (reduces cholesterol)

Question 18

Describe the treatment algorithm for stable angina patients [5]

Answer 18

Sublingual glyceryl trinitrate to abort angina attacks

All patients:
- Aspirin 75 mg
- Statin

1st line:
- Beta blocker: e.g. metoprolol
- CCB: e.g. Amlodopine
- If there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)
- If a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

2nd line:
- a long-acting nitrate: Isosorbide mononitrate
- ivabradine
- nicorandil
- ranolazine

3rd line:
- CABG
- PCI

Question 19

Beta blockers shouldn’t be prescribed alongside which angina medication? [1]

Why? [1]

Answer 19

Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

Coadministration of verapamil and β-blockers results in additive negative inotropic, chronotropic and dromotropic (conduction properties) effects on the heart.

Question 20

If a CCB is being used as first line tx for stable angia, what type should be used? [1]

Give two examples [2]

Answer 20

If a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used.

Question 21

What do you need to consider about nitrate therapy for stable angina? [1]

How do you modifiy treatment to allow for this? [1]

Answer 21

Nitrate tolerance can occur

The BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness

Question 22

Describe the MoA of ivabradine [1]

Answer 22

pacemaker current inhibitor: slows the HR down (not a Beta blocker)

Question 23

Describe the MoA of ranolizine [1]

Answer 23

Late Na current blocker

Question 24

Nicorandil has a rare AE of ? [1]

Answer 24

GI ulceration

Question 25

How can you remember the drugs used for secondary prevention of stable angina patients? [4]

Answer 25

4 As:

A – Aspirin 75mg once daily
A – Atorvastatin 80mg once daily
A – ACE inhibitor (if diabetes, hypertension, CKD or heart failure are also present)
A – Already on a beta blocker for symptomatic relief

Question 26

Why do you get nausea, anxiety or sweating when have ACS? [1]

Answer 26

Undergoing adrenaline surge:

Due to severe ischaemia; causes necrosis; negative feedback loop causes huge amount of adrenaline released

Question 27

Describe the pathophysiology of ACS ]3

Answer 27

Myocardial damage secondary to ischaemia

Generally occurs after following steps:

Step 1 - endothelial dysfunction
* Endothelial injury causes a local inflammatory response.
* If the injury recurs or healing is incomplete, inflammation may continue leading to the accumulation of low-density lipoproteins (LDL).
* These become oxidised by local waste products creating reactive oxygen species (ROS).

Step 2 - plaque formation
* In response to these irritants, endothelial cells attract monocytes (macrophages).
* These engulf (phagocytose) the LDLs swelling to become foam cells and ‘fatty streaks’.

Step 3 - plaque rupture
* Continued inflammation triggers smooth muscle cell migration.
* This forms a fibrous cap, which together with the fatty streaks, develops into an atheroma.
* The top of the atheroma forms a hard plaque.
* This may rupture through its endothelial lining exposing a collagen-rich cap.
* Platelets aggregate on this exposed collagen forming a thrombus that may occlude or severely narrow the vessel.
* Alternatively, the thrombus may break lose, embolising to infarct a distant vessel.

Question 28

How do you assess ACS patient? [4]

Answer 28

ABCD

Airway:
- Patent?

Breathing:
- RR?
- Saturations?
- Pulmonary oedema due to LV impairment can cause hypoxia

Circulation:
- HR
- BP

Disability:
- GCS

DONT FORGET GLUCOSE

Question 29

ACS causing bradycardia can indicate MI in which part of heart? [1]

Why? [1]

Answer 29

Inferior MI

Right coronary artery perfuses the sinoatrial node, heart block and bradycardia may occur

Question 30

go over heart anatomy & SALI

Question 31

What is LDL target for secondary prevention of MI? [1]

Answer 31

< 1.4

Question 32

What are target times for coronary angiography for:

STEMI [1]
NSTEMI [1]

Answer 32

STEMI: < 6 hours
NSTEMI: < 72 hours

Question 33

In cases of primary PCI, which is the first line P2Y12 inhibitor? [1]

Why? [1]

Answer 33

Ticagrelor: most rapidly acting

Question 34

What is the difference between myocardial infarction and myocardial injury? [2]

Answer 34

Myocardial injury = trop > 99% percentile ULN

Acute MI = Injury +
- Symptoms
- ECG changes
- Imaging showing loss of viable myocardium
- Evidence of coronary aetiology
Implies ischaemia

Question 35

What are the key differentials for retrosternal chest pain?

Answer 35

acute coronary syndrome

angina

Panice disorder / anxiety

GORD

pulmonary embolism

pericardial effusion

Costochondritis
- the inflammation of the cartilage that connects a rib to the sternum (breastbone). It can cause localized chest pain that may be aggravated by movement or palpation.

Question 36

Explain to a patient how to take sublingual GTN spray in
the event of chest pain [5]

Answer 36

GTN tablets:

• Sit down.
• Put a tablet under your tongue and close your mouth.
• Allow the tablet to dissolve slowly – do not suck, chew or swallow it.
• Close the container – this is important, so your tablets do not lose their strength.
• Rest for a while, then stand up slowly

GTN spray:
* Sit down.
* If you have not used your spray for over a week, do 1 spray into the air before you use it.
* Hold the nozzle in front of your mouth, with your finger on the button, and take a deep breath.
* Open your mouth and lift your tongue up.
* Spray the GTN under your tongue by pressing once firmly. Do not breathe in while you spray.
* Close your mouth immediately.
* Breathe through your nose keeping your mouth closed.
* Rest for a while before you stand up slowly.
.

Question 37

When should you call 999 after administering GTN? [3]

Answer 37

Call 999 if:
you’ve taken 2 doses of GTN and:
* you’re still in pain 5 minutes after your 2nd dose
* your pain is getting worse
* you feel unwell

Question 38

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

Answer 38

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

Question 39

Patients may develop tolerance to this medication necessitating a change in dosing regime

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

Answer 39

Patients may develop tolerance to this medication necessitating a change in dosing regime

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

Question 40

Why might a patient not be started on both a beta-blocker and CCB, but instead just a CCB, for the first line treament of their angina? [1]

What would be the stepwise treatment if a CCB is not working? [1]

Answer 40

If the beta-blocker is contraindicated - e.g. if they have asthma

if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs:
* a long-acting nitrate
* ivabradine
* nicorandil
* ranolazine