IHD Flashcards

Question

bloods for ACS

Answer 1

FBC U&E CRP glucose lipids cardiac enzymes - CK-MB and cardiac troponin levels (T and I), increase after 12 hours amylase - pancreatitis might mimic MI TFTs AST and LDH increase after 24 and 48hrs respectively - occaisionally used only to make a retrospective diagnosis

Answer 2

regional wall abnormalities measure LVEF - early measurements misleading because of myocardial stunning exercise or dobutamine stress echo may detect inducible wall motion abnormalities

Answer 3

ECG usually normal - may show ST depression, flat or inverted T waves, signs of past MI blood tests - FBC, U&E, TFTs, lipids, HbA1c consider echo and CXR

Answer 4

to determine prognosis and management indicated in trop-negative ACS or stable angina with an immediate or high pre-test probability of CHD positive test - \>= 1mm horizontal or downsloping ST segment depression measured at 80ms after end of QRS failed test - failure to reach at least 85% of predicted max HR (220-age) and otherwise -ve

Answer 5

Uses Tc-99m sestamibi or tetrofosmin can be performed under stress or at rest stress testing would show low uptake in ischemic myocardium rest test can be used in pts with ACS, no previous MI but non-diagnostic troponin and ECGs

Answer 6

if pts cant exercise or if exercise test is inconclusive pharm induce tachy - dipyridamile, adenosine or dobutamine imaging detect ischemic myocardium

Answer 7

in ACS with positive troponin or TIMI score 5-7, or if high risk on stress testing

Answer 8

using specialised CT - role in outpatients with atypical chest pain or in acute chest pain that isn't clearly due to ischemia (absence of CAC excludes obstructive coronary artery disease)

Answer 9

MI have troponin rises, unstable angina doesnt! MI may be STEMI - ST elevation (perhaps only in leads V7-9) or new onset LBBB or NSTEMI - troponin positive ACS w/o ST elevation, may be ST depression, T wave inversion, non-specific changes to ECG, or no changes increase in cardiac biomarkers eg troponin ECG changes of new ischemia development of pathological Q waves new loss of myocardium regional wall motion abnormalities on imaging

Answer 10

* exercise ECG - look for ischemic ECG changes * angiography - either cardiac CT with contrast pr angiography * functional imaging - myocardial perfusion scinitigraphy, stress echo (echo while undergoing exercise or receiving dobutamine), cardiac MRI Typical angina in a patient with previously proven IHD: Treat as stable angina; if further confirmation is required, use non-invasive testing, eg exercise ECG. Typical and atypical angina: CT angiography. If inconclusive, use functional imaging as 2nd line and transcatheter angiography as 3rd line.

Answer 11

Both will require the same initial management, but a STEMI will require urgent percutaneous coronary intervention (PCI: angiogram +/- stenting). Manage in ABCDE approach o Oxygen and cardiac monitoring - myocardial muscle needs Ox - 15L via non-rebreathe mask first and continual cardiac monitoring o Anti-ischemic therapy – nitrates - GTN spray, administered under tongue and will dilate the coronary arteries o Antiplatelet agents – aspirin and clopidogrel (300mg of both) o Call cardiologist - because eventually the coronary vessels need to be opened by angioplasty o Anti-coagulation – heparin, LMWH, fondaparinux o Blood: Trop-T, FBC, U&E, VBG - gives instant HB because anaemia worsens ischemia, XMatch o Call surgical senior o=ACE inhibitor and statin

Answer 12

manage chest pain with PRN GTN and opiates if this is insufficient give GTN infusion - monitor BP - omit if recent sildenafil use if pain deteriorating seek senior help

Answer 13

pts should be advised and helped to stop smoking identify and treat dm, hypertension and hyperlipidaemia advise a diet high in oily fish, fruit, veg and fibre and low in saturated fats daily exercise refer to cardiac rehab programme flag depression/anxiety to GP - independently associated with poor CV outcomes

Answer 14

antiplatelets: aspirin (75mg OD) and 2nd antiplatelet eg clopidogrel for at least 12 months to reduce vascular events eg MI or stroke. Consider adding PPI for gastric protection anticoagulant until discharge he fondaparinux B blockage reduces myocardial ox demand - start low and increase slowly, monitoring pulse and BP, if contraindicated consider verapamil or diltiazem ACE-i in patients with LV dysfunction, hypertension or dm unless not tolerated - titrate slowly monitoring renal function high dose statin - atorvastatin 80mg echo to assess LV function - eplerenone improves outcomes in MI patients with HF (ejection fraction \<40%)

Answer 15

STEMI and very high-risk NSTEMI (eg haemodynamically unstable) - immediate angiography +- PCI NSTEMI patients who are high risk (eg GRACE score \>140) should have angiography within 24h; intermediate risk (eg GRACE109–140) within 3d; low-risk patients may be considered for non-invasive testing. multivessel disease may be considered for CABG instead of PCI