ischaemic disease

Question 1

what is atherosclerosis?

Answer 1

hardneing of the arteries due to non-plaque factors

Question 2

what is angina and characteristics

Answer 2

a symptom of CHD

• insufficient oxygen supply to myocardium (ischaemia)
• pain in the chest/ arm/ neck , sweating and breathlessness

Question 3

4 types of anginas?

Answer 3

stable angina
unstable angina
variant angina
microvascular angina

Question 4

what is stable angina?

Answer 4

predictable pain - on exertion e.g whilst doing exercise

almost always caused by atheroma (plaque)

Question 5

what is unstable angina - acute coronary syndrome

Answer 5

pain on less and less exertion or at rest

normally caused by ruptured atheroma - not just plaque

Question 6

what is variant angina?

Answer 6

rare
often artery spasm
normally associated with atheroma

Question 7

microvascular angina

Answer 7

not always due to atheroma
pain = severe
may not respond to normal treatments for angina

Question 8

What is MI and causes

Answer 8

Myocardial infarction

• caused by coronary artery block by rupture of atheroma and thrombus formation
• loss of oxygen area of heart supplied by blocked coronary artery - prolonged loss of oxygen - irreversible cell death -apoptosis or necrosis

Question 9

What are symptoms of MI

Answer 9

similar to angina attack

pain in the chest/ arm/ neck , sweating and breathlessness

Question 10

what are the 3 steps of diagnosis for MI (WHO)

Answer 10

• patient history of chest pain, angina and unstable angina \
• ECG changes
• cardiac biomarkers - troponin

Question 11

What is STEMI?

Answer 11

ST segment is elevated

Question 12

what is NSTEMI?

Answer 12

ST segment normal (of ECG)

Question 13

name an organic nitrate and use

Answer 13

glyceryl trinitrate (GTN)
cause relaxation of smooth muscle by liberation of nitric oxide and generation of cGMP.
- dilate coronary artery - re-distrubute blood to ischaemic regions
-reduce cardiac oxygen consumption
-prevent/relieve coronary spasm

Question 14

what are the problems caused by organic nitrates

Answer 14

• prone to develop tolerance - avoid by having nitrate overnight
• action is short - passes first pass metabolism as it is a spray or sublingual tablets and rapidly absorbed into the blood stream
• side effects: flushing , headache, postural hypertension

Question 15

what are examples of calcium channel blockers

Answer 15

Diltiazem and verapamil

Question 16

what is the use of calcium channel blockers

Answer 16

vasodilators 
reduce heart rate 
reduce force of contraction 
dilate arteries 
reduce oxygen demand of heart, dilate coronary arteries

Question 17

what are examples of b1 receptors

Answer 17

atenolol and bisoprolol

carvedilol

Question 18

what is the function of b1 adrenoreceptor antagonist

Answer 18

reduce oxygen demand of the heart by inhibiting sympathetic drive to heart

Question 19

what is angioplasty: percutaneous coronary intervention (PCI)

Answer 19

• catheter inserted in femoral or radical arteries
• stents placed in narrowed coronary artery
• stent is expanded increasing arterial diameter and blood flow

Question 20

what is angioplasty: coronary bypass

Answer 20

taking a healthy blood vessel form the hands or legs and connecting it below and above the arteries in the heart to redirect the blood from the blocked artery.

Question 21

management of first presentation of chest pain - ACS

Answer 21

• check last episode of cheat pain - to rule out any non -cardiac pain
• assess symptoms
  chest pain longer than 15 min
  pain associated with nausea, vomiting, sweating, breathlessness
  new onset deterioration of stable angina
  -refer as emergency is ACS is suspected or currently has chest pain or 12 lead abnormal ECG
  refer for same day assessment: pain last 12 hours but pain free now, last episode was 12-72 hours ago

Question 22

what is the management of stable angina

Primary and secondary

Answer 22

organic nitrate - management of pain episodes
b blocker - prophylaxis of angina pain
calcium channel blockers + BB used in resistant angina

secondary prevention

• low dose aspirin
• statin
• ace inhibitor
• treatment for hyper tension
• does patient need pci/angioplasty

Question 23

what is the treatment of ACS (unstable angina and NSTEMI)

Answer 23

aspirin 300mg until clinical decision is made
angiogram - high risk patients
PCI angioplasty if required
low risk dual antiplatelets ticagrelor with aspirin

secondary:

• drug therapy - 12 month dual antiplatlets
• acei or arb
• beta blocker 12 months - bisoprolol (if contradicted verapamil or diltiazam)
• statin

Question 24

treatment for STEMI

Answer 24

• pre-treatment - 300mg aspirin (until clinical decision is made)
• reperfusion therapy - PCI
• dual antiplatelets therapy for 12 months( prasugrel (check bleeding risk ) with aspirin)
• If PCI not an option - fribrinolytic drugs - steptokinase and alteplase

secondary:

• drug therapy - 12 month dual antiplatlets
• acei or arb
• beta blocker 12 months - bisoprolol (if contradicted verapamil or diltiazam)
• statin

Question 25

examples Fribinolytic

Answer 25

Streptokinase and altepase