IHD

Question 1

What is stable angina?

Answer 1

Chronic chest pain/discomfort brought on by exercise and relieved by rest/ GTN spray- caused by reversible myocardial ischaemia

Question 2

What are common Px features for stable angina

Answer 2

Male, >55yrs

Question 3

What is the cause of stable angina

Answer 3

Mismatch of oxygen supply and demand
Reduced supply often caused by atherosclerosis (incr. peripheral resistance and arterial stenosis)
Increased demaned: exersion

Question 4

What are the modifiable risk factors for stable angina?

Answer 4

Obesity
DM
Hyperlipidaemia
Sedentary lifestyle/ poor diet
Hypertension
Tobacco smoking

Question 5

What are the non-modifiable risk factors for stable angina?

Answer 5

Age
Gender (M)
FHx/ PMH

Question 6

What factors may exacerbate stable angina?

Answer 6

Physical activity
Cold
Emotional stress
Eating a heavy meal

Question 7

What is the clinical presentation of stable angina?

Answer 7

Chest pain
- radiating to neck/ jaw
- induced by exertion
- relieved by rest (5min/ GTN spray)

Breathlessness

Question 8

What are the investigations and results for stable angina?

Answer 8

ECG
- ST depression
- flat or inverted T waves
Coronary angiogram
Bloods
- FBC, U&E, Lipids, HBA1c

Question 9

What are the features of an ECG showing stable angina?

Answer 9

ST depression
Inverted or flat T waves

Question 10

What is the average % arterial occlusion that causes ischaemic symptoms / stable angina?

Answer 10

70% occlusion

Question 11

What are the differential diagnoses for stable angina

Answer 11

Pyschological
Pericarditis
PE
Gastro-oesophageal reflux/ ulcers

Question 12

What drug is maily used for stablee angina symptom relief and how does it work and SE?

Answer 12

GTN spray - sublingual
- venodilator
- reduces venous return so reduces heart preload
- SE = flushin, headache and lightheadedness

Question 13

What are the SE for GTN spray?

Answer 13

Light headedness, flushing, headache

Question 14

What is the first line treatment for stable angina?

Answer 14

• symptom relief = GTN spray
• BB or CCB
  (BB eg bisoprolol or atenolol)
  (CCB eg amlodipine)

Question 15

What is the second line drug treatment for stable angina?

Answer 15

CCB and BB - non rate limiting

Question 16

What is the 3rd line drug treatment for stable angina?

Answer 16

CCB, BB, long acting nitrate

Question 17

What therapy is considered it drug treatment is unsuccessful for stable angina

Answer 17

Revascularisation
- PCI (stent- a antiplatelets eg clopidogrel to red. risk thrombosis)
- CABG (coronary antiplatelet bypass grafting)

Question 18

Which conditions make up acute coronary syndrome?

Answer 18

Unstable angina
Non-STEMI
STEMI

Question 19

What is the shared pathophysiology of ACS?

Answer 19

Rupturing of fibrous cap of an atherosclerotic plaque in coronary artery
Causing thrombus formation which occludes vessels

Question 20

What are the causes for ACS?

Answer 20

Thrombus formation in coronary artery
Less likely
- vasculitis
- coronary spasms in normal coronary arteries
- emboli

Question 21

What is unstable angina?

Answer 21

Chest pain/ discomfort at rest due to myocardial ischaemia (partial occlusion of a minor coronary artery) with the absence of infarction

Question 22

What is a non-STEMI?

Answer 22

Non ST elevated myocardial infarct
- myocardial infarction due to partial/ near complete occlusion of coronary artery resulting in ischaemia and tissue necrosis (infarction)

Question 23

What is a STEMI?

Answer 23

ST- elevated myocardial infarct
- MI due to complete occlusion of a major coronary artery
-ST elevation in local ECG leads

Question 24

What are the risk factors for ACS?

Answer 24

Age
Gender
Obesity, DM, Hypertension, Hyperlipidaemia
Tobacco smoking
FH

Question 25

What FH puts Px at increased risk for ACS?

Answer 25

1st degree relative w IHD <55yrs

Question 26

What is the clinical presentation for ACS?

Answer 26

Central heavy crushing chest pain - >20min - radiating to jaw and neck - Angina- incr severity Chest pain at rest- not relieved by stress or GTN spray Sweatiness/ pallor Distress/ sense of doom Dysponea

Question 27

Describe an ECG for a STEMI

Answer 27

- ST elevation - pathological q waves - LBB

Question 28

Describe an ECG for non-STEMI

Answer 28

- ST depression - T wave inversion - no Q waves

Question 29

Describe an ECG for unstable angina

Answer 29

- normal - may show st depression/ t wave inversion

Question 30

What is the biochemical marker for MI?

Answer 30

Troponin - released in cell death - myocardial necrosis - non specific to MI

Question 31

Is troponin released in unstable angina?

Answer 31

No

Question 32

What is the acute drug treatment for STEMI

Answer 32

MONAC - morphine - oxygen (<94%sat) - nitrates (GTN spray) - aspirin (loading dose 300mg) - clopidogrel

Question 33

What are the acute interventions for STEMI?

Answer 33

PCI- first 2 hrs medical contact Thrombolysis- fibrinlytic medication given to dissolve clot

Question 34

What is the acute drug treatment given for non-STEMI/ unstable angina?

Answer 34

MONA - morphine - oxygen (<94% sat) - nitrates (GTN spray) - aspirin (loading dose 300mg)

Question 35

What test/ scoring system is used to determin risk of MI mortality after unstable angina/ non-stemi?

Answer 35

GRACE score - predict MI mortality in next 6mth- 3 yr)

Question 36

What is the treatment plan for Px who score high and low for the GRACE score?

Answer 36

(GRACE = MI Mortality used for ACS Px) Low- monitor High- angiogram and consider PCI

Question 37

What is the long term drug prevention for ACS Px?

Answer 37

BB, aspirin (75mg), atorvastatins, ACEi (all life) clopidogrel 12 mnth 75mg

Question 38

What are the complications from ACS?

Answer 38

Death Dresslers syndrome Heart failure Arrhythmia

Question 39

What are the complications from ACS?

Answer 39

Death Dresslers syndrome Heart failure Arrhythmia

Question 40

What is Dresslers syndrome?

Answer 40

Autoimmune pericarditis occuring usually 2-3 weeks after MI Treat w NSAID presents w pleuritic chest pain

Question 41

Why may diabetics have silent MI?

Answer 41

Diabetic neuropathy