IHD

Question 1

Describe stable angina

Answer 1

induced by effort, relieved by rest

Question 2

What type of angina is described by “Occurs at rest or recent onset, increases in severity, high risk of MI”

Answer 2

Unstable angina

Question 3

When does decubitus angina occur?

Answer 3

When lying down

Question 4

Angina is mostly caused by atheroma, what are its other causes?

Answer 4

Anaemia
Aortic stenosis (AS)
Tachyarrhymias
Hypertrophic cardiomyopathy (HCM)
Arteritis/small vessel disease (microvascular angina/cardiac syndrome X)

Question 5

Describe the typical chest pain experienced by a patient with angina

Answer 5

Central crushing retrosternal chest pain
Comes on with exertion and relieved upon rest
Radiates to arms and neck
Exacerbated by: cold weather, anger, excitement, heavy meals

Question 6

Other than chest pain what other symptoms are associated with angina?

Answer 6

sweatiness, dyspnoea, faintness and nausea

Question 7

What are the different causes of chest pain?

Answer 7

Angina 
MI
Pericarditis
Acute coronary syndrome 
MSK 
GORD
Pulmonary embolism 
Myocarditis 
Aortic dissection

Question 8

An ECG in a patient with angina is usually normal, however when a patient is experiencing an acute attack it will show signs of ischaemia. What are these signs?

Answer 8

ST depression

T wave inversion

Question 9

If a patient is suffering asymptomatic pain and has no risk factors for angina, further testing is required. What tests are these?

Answer 9

Exercise ECG and functional imaging (coronary angiography

Question 10

What ECG signs in an exercise test indicate a positive result? A positive test is an indication for further angiography

Answer 10

ST depression at low workload

Paradoxical fall in blood pressure with increased work load.

Question 11

If a patient is unable to do an exercise test what alternative is often undertaken?

Answer 11

Drug induced stress test

Question 12

What secondary preventative measures are taken in patients with angina, to prevent MI, stroke ect.

Answer 12

Risk factor modification
Low dose aspirin (75mg daily)
Clopidogrel is an aspirin alternative
Lipid-lowering agents – statins, fibrates

Question 13

How does aspirin work as an anti-platelet

Answer 13

inhibits COX2 and formation of thromboxane A2 (platelet aggregating agent)

Question 14

Clopidogrel is alternative to aspirin, how does it work?

Answer 14

P2Y12 receptor inhibitor

Question 15

What symptomatic treatment is offered to patients with angina?

Answer 15

Sublingual GTN spray for acute attacks
β-blockers – e.g. atenolol, metroprolol.
Calcium channel blockers (calcium antagonists) e.g. diltiazem, amlodipine
Nitrates e.g. isosorbide mononitrate, slow release preparations may be given for prophylaxis

Question 16

What is a common side effect of GTN spray

Answer 16

severe headache

Question 17

What are contraindications to B Blocker usage

Answer 17

ASTHMA, COPD, LVF, bradycardia, coronary artery spasm.

Question 18

What is effect of Calcium channel blockers

Answer 18

Relaxes the coronary arteries and reduces force of LV contraction, thus reducing oxygen demand.

Question 19

What is a Percutaneous coronary intervention (PCI)?

Answer 19

catheter inserted, balloons used to dilate atheromatous areas of arteries. Stents can be placed.

Question 20

When preforming a PCI what drugs should be given to reduce risk of a) clotting b) procedure related ischaemic events?

Answer 20

a) clopidogrel (anti-platelet)

b) IV glycoproteins IIb/IIIa inhibtiors (e.g. eptifibatide)

Question 21

What disease does acute coronary syndrome cover?

Answer 21

Unstable angina
NSTEMI
STEMI

Question 22

Describe the common pathology to acute coronary syndrome caused by atheroma (main cause)

Answer 22

Rupture/ erosion of fibrin rich cap on a coronary artery atheromatous plaque. (Rupture more likely with a lipid rich core)
Formation of a platelet rich clot
Vasoconstriction produced by platelets releasing thromboxane A2 and serotonin

Question 23

How is an unstable angina differentiated from NSTEMI

Answer 23

NSTEMI will show rise in Troponin and creatine kinase

Question 24

What are non modifiable risk factors for ACS?

Answer 24

Age
Male
FHx of IHD (MI in 1st degree relative <55yrs)

Question 25

Describe the clinical presentation of acute coronary syndrome

Answer 25

Acute central chest pain >20mins Dyspnoea Palpitations Pallor, sweatiness Signs: Pulse may be high or low BP high or low 4th heart sound

Question 26

What test should be done on a patient experiencing acute coronary syndrome?

Answer 26

Bloods- FBC, U&E, glucose, lipids ECG Cardiac enzyme test

Question 27

What ECG changes are expected in a patient with acute coronary syndrome?

Answer 27

Hyperacute (tall) T waves ST elevation (if STEMI) ST depression in NSTEMI/unstable angina New LBBB (S shape in V1 and V2 , M in V5 and V6 and broad QRS) Over the next hrs-days = T wave inversion, pathological Q waves

Question 28

What enzymes are measured to assess cardiac damage ?

Answer 28

Troponin (T and I) (specific) Creatine kinase (non specific) Myoglobin

Question 29

What does MONA(T) stand for with regard to the treatment of acute coronary syndrome

Answer 29

``` Morphine Oxygen Nitrates Aspirin (T)- if severe ticragelor or clopidogrel ```

Question 30

Metoclopramide is often given with morphine or diamorphine, what is its purpose?

Answer 30

Anti- emetic

Question 31

Anti- anginal therapy is important in the long term management of acute coronary system, what does this include?

Answer 31

beta blocker, nitrates, calcium antagonist

Question 32

What is fondaparinux?

Answer 32

anti coagulant- factor 10a inhibitor, interferes with thrombus formation at the site or Heparin

Question 33

Describe clinical presentation of an acute stemi

Answer 33

Central crushing chest pain, similar to angina Differs from angina as: occurs at rest, is more severe, lasts up to several hours Sweating, breathlessness, nausea, vomiting, restlessness Patient appears pale and grey

Question 34

Diagnostic tests and results for acute STEMI

Answer 34

Take brief history to ID risk factors ``` ECG- will show: Tall, peaked T waves ST elevation After a few hours T waves invert Pathological Q waves develop Will return to normal eventually, although Q waves remain – may take months for T waves to return to upright ``` Bloods- cardiac enzymes Xray if there is time

Question 35

Changes are typically confined to leads that are “looking at” the infarcted area and opposite leads show reciprocal change. What leads would demonstrate an inferior infarct

Answer 35

2, 3 and aVF= inferior infarct

Question 36

Changes are typically confined to leads that are “looking at” the infarcted area and opposite leads show reciprocal change. What leads would demonstrate an anterior infarct?

Answer 36

V2-V6

Question 37

Changes are typically confined to leads that are “looking at” the infarcted area and opposite leads show reciprocal change. What leads would show a lateral infarct

Answer 37

1, 2 and aVL show lateral infarct

Question 38

From hospital admission, how would you manage an acute STEMI

Answer 38

1) attach ECG and record 2) Establish IV access, bloods for- FBC,U&E, glucose, lipids, cardiac enzymes 3) Brief assessment: risk factors for CVS disease. Assessment of pulse BP ect. Check for contraindications for PCI or fibrinolysis 4) Aspirin 300mg (unless already given by paramedics) 5) Morphine + metoclopramide IV 6) If STEMI on ECG and PCI available within 120mins—> PCI . If not—> Fibrinolysis, then transfer to PCI centre.

Question 39

When managing an acute STEMI, what should you do to prevent hyperglycaemia (glucose >11mmol/L)? Hypoxia? Tachycardia

Answer 39

insulin infusion Oxygen B blocker