Cardiology (Ischaemic heart disease) Flashcards
(47 cards)
QRISK
Calculates a 10-year estimated risk of developing a cardiovascular disease (CVD, angina, myocardial infarction, stroke, TIA, or peripheral arterial disease). It is expressed as a percentage
For example, if someone’s QRISK score is 30%, this means they have a 30% chance (3 in 10) that they will develop a cardiovascular disease.
primary prevention depending on QIRISK score
Primary prevention involves reducing the risk of CVD in people who have never had CVD.
Patients with a QRISK score ≥10% should be offered a statin.
Management
- Atorvastatin 20 mg is offered first-line.
- For patients ≥85 years old, consider offering atorvastatin (as these patients are not included in QRISK assessments).
patients with which conditions should be offered statins as primary prevention
Type 1 diabetes mellitus
Chronic kidney disease (CKD)
Secondary prevention
Involves treatment after a diagnosis of CVD to reduce the risk of further cardiovascular events (such as myocardial infarction or stroke). It depends on the specific condition.
All patients with CVD should be given a statin in the absence of any contraindication.
Atorvastatin 80 mg is first-line.
monitoring of statin use
Patients taking statins are followed up at 3 months where a lipid profile and liver function tests (LFTs) are measured.
- If non-HDL cholesterol has not fallen by at least 40%, discuss adherence and lifestyle changes and consider increasing the dose to 80 mg.
- Statins can cause a transient increase in AST and ALT during the first few weeks of use. They do not need to be stopped if the increase is <3 times the upper limit of normal.
angina pathophysiology
Angina describes chest pain or discomfort in the chest, neck, shoulders, jaw, or arms due to an insufficient blood supply to the heart muscle. It is usually caused by atherosclerosis – where arteries are narrowed due to fatty plaques. Angina can also be caused by valvular disease, hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.
stable angina
Angina is said to be stable if it occurs predictably with physical exertion or emotional stress, does not last for more than 10 minutes, and is relieved with rest and the use of sublingual nitrates.
Unstable angina
describes a sudden worsening in angina occurring at rest and requires immediate hospital admission. It should be managed as a form of acute coronary syndrome.
stable angina is not
an acute coronary syndrome
angina risk factors
Risk Factors
- Increased age
- Smoking
- Hypertension
- Elevated LDL cholesterol
- Diabetes mellitus
- Obesity
- Illicit drug use
- Inactivity
- Male sex
- Cardiac abnormalities e.g. aortic stenosis/hypertrophic obstructive cardiomyopathy
The typical presentation of angina has 3 characteristics:
- The pain is crushing or squeezing (may be central and may radiate to the jaw or arms)
- The pain is provoked by exercise or emotional stress
- The pain is relieved by rest or using glyceryl trinitrate (GTN)
delete
delete
Atypical angina
has only 2 of the 3 features, meaning they may not have any chest pain at all. It is usually seen in:
Women
People with diabetes
The elderly
when does angina become acute coronary syndrome
- Chest pain is not relieved with rest and is not relieved with GTN spray
- Shortness of breath, nausea and vomiting, sweating, and palpitations may occur
investigations for angina
- resting ECG
- Hb
- lipid profile
- HbA1c
- CT coronary angiogram
management of angina
- aspirin
- statin
- sublingual GTN spray
- a drug to provide long term relief
Long-term relief of anginal symptoms
🟢 1st-line:
- Use a beta-blocker (e.g. bisoprolol)
- OR a rate-limiting CCB (e.g. verapamil)
- ⚠️ Don’t mix beta-blockers with verapamil/diltiazem — risk of heart block
- If combining, use a non-rate-limiting CCB (e.g. amlodipine)
🟡 2nd-line:
- Increase dose to max tolerated
- Or switch or combine the two (safely)
🔴 3rd-line:
- If symptoms persist:
- Add another anti-anginal (e.g. nicorandil)
- If already on both main drugs → refer for PCI or CABG
Other anti-anginal drugs
if first and second line fail
- Long-acting nitrates e.g. isosorbide mononitrate
- Ivabradine
How should Long-acting nitrates e.g. isosorbide mononitrate be prescribed
To reduce tolerance = Use asymmetrical dosing intervals (e.g. longer gap overnight)
This gives the body a nitrate-free period to prevent tolerance
how do nitrates work
- Used for angina and heart failure
- Cause vasodilation by increasing cGMP and reducing calcium
Examples of nitrates are:
- GTN spray – for acute angina attacks
- Isosorbide mononitrate – for angina prevention
Key side effects of nitrates are:
- Headaches
- Tachycardia
- Flushing
- Hypotension
Contraindications to nitrates include:
- Aortic stenosis
- Cardiac tamponade
- Hypertrophic cardiomyopathy
- Hypotension
- Hypovolaemia
- Constrictive pericarditis
- Increased intracranial pressure secondary to pulmonary oedema
acute coronary syndrome symptoms occur due to
ischaemia in the myocardium
acute coronary syndrome is an umbrella term for
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI)
- Unstable angina
NOT STABLE ANGINA
