CCS - HARD

Question 1

location of chest pain

Answer 1

• retrosternal
• L arm - jugular

fist size

Question 2

tests for IHD

Answer 2

use stress conditions to look for ischemia
- exersize ECG
- MRI
- PET

Question 3

prognostic treatment

Answer 3

lipid modification:
- statins
- ezetimbe - 2nd line
- PCSK9 inhibitors

antiplatelet:
- aspirin
- clopidogrel

revascularisation:
- angioplasty + stents
- bypass surgery

Question 4

lifestyle modification - LDL target

Answer 4

<1.4
50%+ reduction

Question 5

symptomatic treatment

Answer 5

CCB
BB
nitrates
potassium channel blockers

ivabradine - slows SAN reducing HR

ranolazine - inhibits Na - less contraction

Question 6

ANOCA main gender effected and possible main cause

Answer 6

women
diseases that effect the microvessels

Question 7

stable angina medication

Answer 7

• short acting nitrate
• 75mg daily of aspirin
• ACE inhibitors
• statin

Question 8

how to assess chest pain?

Answer 8

OPQRST
- onset
- position (site)
- quality (nature/character)
- relationship (with exersize)
- radiation
- relieveing or aggrevating factors
- severity
- timing
- treatment

Question 9

4 types of angina

Answer 9

• stable - normal 3 point definition
• unstable - pain at rest, not relieved by inactivity or GTN spray - no ECG changes
• prinzmetals - due to coronary vasospasm - cocaine users - ST elevation
• decubitus - induced when lysing flat + usually a complication of cardiac failure

Question 10

diagnosis of stable angina occlusion

Answer 10

70-80%

Question 11

reasons for imperfect blood supply

Answer 11

• atherosclerosis
• thrombosis
• thromboemboli
• artery spasm
• collateral blood vessels
• blood pressure / cardiac output / heart rate
• arteritis

Question 12

side effect of aspirin

Answer 12

gastric ulceration

Question 13

side effects of BB

Answer 13

• erectile dysfunction
• tiredness
• nightmares
• bradycardia
• cold hands and feet

Question 14

symptoms of IHD

Answer 14

central crushing chest pain radiating to jaw/neck, worsens over time

nausea
sweating
fatigue
dyspnoea
impending sense of doom palpitations

Question 15

symptoms not associated with angina

Answer 15

no fluid retention
palpitations
syncope / pre-syncope

Question 16

stable angina - if CCB/BB contradicted

Answer 16

ranolazine
ivabradine
nicorandil

Question 17

what vessels can CABG use?

Answer 17

• internal mammary artery from chest
• saphenous vein from leg

Question 18

stable angina - secondary prevention

Answer 18

3As:
- atovastatin 80mg
- aspirin 75mg
- acei

if peristance occurs:
- PCI
- CABG

Question 19

long term relief stable angina

Answer 19

CCB
BB

if not tolerated:
ivabradine
nicorandil

Question 20

acts of GTN

Answer 20

vasodilation

Question 21

talk through all the different medications and when they would be used

Answer 21

1. initial medication - symtpom relief:
   - BB (bisoprolol)
   - if BB not good - switch to CCB (virapamil / diltiazem)
   DO NOT COMBINE

if this doesnt work:
- bisoprolol + amlodipine / nifedipine

if this doesnt work:
- bisoprolol + amlodipine / nifedipine + long acting nitrate

if cant use long acting nitrate:
ranozaline
nicorandil
ivabradine is HR>70

2. prevent progression
   - 75mg aspirin
   - 80mg atorvastatin
   - ACEi

contraindications:
swap aspirin for clopidogrel
if remains high add ezetimibe then if still doesnt work add PCSK(

Question 22

when should you inform the DVLA if you have angina

Answer 22

when its bought on by no exersion - pain at rest

Question 23

1st line diagnostic technique

Answer 23

CT coronary angiography

Question 24

what should you never prescribe beta-blockers with because of a risk of heart block

Answer 24

verapamil
diltiazem

Question 25

costrochondritis

Answer 25

- inflammation where your costal margin is - It can cause sharp chest pain, especially when moving or breathing - It usually gets better on its own over time. - usually thought to be a heart atack - localised to single point - young fit people treatment: - hydration - algesia - NSAIDs

Question 26

when should you not give ivabradine

Answer 26

HR <70

Question 27

isosorbide mononitrate (ISMN)

Answer 27

nitrate

Question 28

choice of CCB

Answer 28

rate-limiting eg verapamil, diltiazem NOT IN ADDITION TO BETA BLOCKERS

Question 29

if the patient is on 2 antianginals with low BP, what do you add?

Answer 29

long acting nitrate Nicorandil Ranolazine (ivabradine if BP >70)

Question 30

when administering a CCB + BB what should the CCB be?

Answer 30

Amlodipine or Felodipine otherwise both negative inotrophic

Question 31

stable angina classification

Answer 31

Class I: no angina with normal physical activity. Strenuous activity may cause symptoms. Class II: angina pain causes slight limitation on normal physical activity. Class III: angina causes marked limitation on normal physical activity. Class IV: angina occurs with any physical activity and may occur at rest (see unstable angina).