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Flashcards in Ischaemic Heart Disease Deck (50):
1

Epidemiology IHD?

-8M:1F

2

Non modifiable RFx for atherosclerotic heart disease?

-Age
-Male, post menopause female
-FHx MI

3

Modifiable RFx for atherosclerotic heart disease?

-Hyperlipidemia
-HTN
-DM
-Smoking
-Metabolic syndrome / Obesity
-Sedentary lifestyle
-Heavy EtOH

4

What is chronic stable angina most commonly caused by?

Fixed stenosis caused by an atheroma.

5

What is chronic stable angina?

Symptoms complex resulting from an imbalance between oxygen supply and demand in the myocardium.

6

Symptoms stable angina

retrosternal CP radiating to the arm / shoulder/ neck / jaw a/w N and diaphoresis.

7

Precipitants of stable angina?

-Exertion
-Emotion
-Eating

8

What is Levine's sign?

Clutching fist over sternum when describing CP

9

Hx features in stable angina?

-HOPC
-Directed RFx assessment

10

Ix stable angina?

-Bloods: Hb, fasting lipids / glucose
-CXR
-ECG
-+/-Angio / stress test
-Echo

11

Drugs for consideration in management of stable angina?

-Antiplatelet: aspirin
-B-blocker: metoprolol
-Nitrates
-CCBs
-ACEi

12

General measures in Mx chronic stable angina?

Control RFx
-Lifestyle modification -> diet and exercise
-Treat RFx: statin, control HTN and BSLs as indicated

13

Are B-blockers indicated in chronic stable angina? Why?

First line therapy - decrease overall mortality.
-increase coronary perfusion and decrease demand (HR, contractility) and BP (after load).

14

Role of nitrates in chronic stable angina?

-Reduce preload (venous dilation)
-Reduce after load (arteriolar dilation)
-Increase coronary perfusion

15

Can nitrates be taken daily?

No. Maintain daily nitrate free intervals to prevent tachyphylaxis.

16

Are CCBs first line in Mx chronic stable angina?

No. 2nd line or combo.

17

How does CCBs assist in chronic stable angina?

Increase coronary perfusion and decrease demand (HR, contractlity) and BP (after load).

18

When must caution be exercised w/ CCBs?

-Verapamil / diltiazem combined with B-blocers may cause symptomatic sinus brady / AV block.

19

Are ACEi used to treat symptomatic angina?

NO! Pts w/ angina tend to have CV RFx which indicate ACEi intervention.

20

What is Prinzmetal's angina?

Aka variant angina.
Myocardial ischaemia 2" to vasospasm. Typically occurs b/w midnight and 8am.
ST elevation on ECG.
Rx: nitrates and CCBs

21

What is syndrome X?

Typical angina symptoms but normal angio. Exercise test may show schema. ?inadequate vasodilator reserve of coronary resistance vessels.

22

What is ACS?

Includes spectrum of UA, NSTEMI, STEMI and sudden cardiac death.

23

How is MI diagnosed?

Any 2 of:
i) symptoms of ischaemia
ii) ECG changes
iii) -Rise/fall of serum markers (troponin or CK)

24

ECG changes required for MI diagnosis?

-ST-T changes
-New BBB
-pathological Q waves

25

How is NSTEMI diagnosed?

-meets criteria for MI w/o ST elevation of BBB

26

How is STEMI diagnosed?

-meets criteria for MI characterised by ST elevation of new BBB

27

How is UA defined?

Clinically defined by any of:
-accelerating pattern of pain
-angina at rest
-new-onset angina
-angina post -MI / -procedure

28

Ix in ACS work up?

-Hx and Ex
-ECG
-CXR
-Troponin / CV biomarkers
-FBE
-Coags
-UEC
-CMP
-Glucose
-Lipids

29

General measures in ACS Mx?

-ABCs
-O2
-Rest, monitoring
-Nitroglycerin
-IV morphine

30

Treatment of NSTEMI?

BEMOAN
-B-blocker
-Enoxaparin
-Morphine
-O2
-ASA
-Nitrates

31

What are the complications of MI?

CRASHPAD
-Cardiac Rupture
-Arrhythmia
-Shock
-HTN/HF
-Pericarditis /PE
-Aneurysm
-DVT

32

Contraindications to B-blocker in STEMI?

-Signs of heart failure
-low output states
-Risk of cardiogenic shock
-Heart block
-Asthma or airway disease

33

When and which are CCBs used in STEMI Mx?

-If B-blockers CIx or fail to relieve ischaemmia
-Non-dihydropyridine CCBs (e.g. diltiazem, verapamil)

34

Invasive / reperfusion strategies in UA/NSTEMI?

-Early coronary angiography +/- revascularisation

35

reperfusion options in STEMI?

Thrombolysis or PCI

36

When is thrombolysis preferred in STEMI Mx?

In patients presenting early after the onset of chest pain (less than 1-2 hours) and in certain clinical subsets (less than 65 years-of-age, anterior STEMI), prehospital fibrinolysis may offer similar outcomes compared to PPCI. Benefit if PCI not available.

37

Thrombolysis v PCI as first preference?

PCI superior efficacy and safety to thrombolysis in STEMI, performed within 90 minutes of patient arrival, whether in high or low volume centres, with or without on-site cardiac surgery. Benefits maintained up to five years follow up.

38

Absolute Cix to thrombolysis in STEMI?

-1. Prior intracranial haemorrhage
-2. Known structural vascular lesion
-3. CNS system damage, neoplasms or structural vascular lesion (i.e. AV malformation)
-4. Recent major trauma / surgery / head injury (within 3 weeks)
-5. GIT bleeding within the last month
-6. Ischaemic stroke past 6 months
-7. Known bleeding disorder
-8. Aortic dissection

39

Pre-discharge work up post ACS?

-ECG
-Echo
Assess residual LV systolic function

40

What is sudden cardiac arrest?

Unanticipated, non-traumatic cardiac death in a stable pt which occurs w/in 1h or symptoms onset; VFib most common cause.

41

Aetiology of sudden cardiac arrest?

Primary cardiac pathology:
-ischaemia/MI
-LV dysfunction
-severe V hypertrophy (HCM, AS)
-long QT syndrome
-congenital heart disease
-mutations in cardiac ion channels

42

Acute Mx sudden cardiac arrest?

-CPR and defib

43

Mx sudden cardiac arrest?

-Ix underlying cause
-Treat underlying cause
-Antiarrhythmic drug therapy: amiodarone, B-blockers
-Implantable cardiac defib

44

Presenting Sx of IHD?

-Ischaemic CP
-SOB
-Palpitatons
-Syncope
-Lethargy

45

Target period for PCI in STEMI?

Goal: door to balloon time

46

Adjunctive therapies (Rx) in acute MI? (i.e. in addition to revascularisation)

-O2
-IV morphine
-Aspirin
-IV heparin / SC clexane
-IV GTN
-Additional anti platelets if stent inserted
-B blockers
-ACEi

47

Evidence for B-blcokers in acute MI?

B blocker post acute MI reduce morbidity and mortality.
-Reduce rate of recurrence
-Reduce angina
-reduce arrhythmias
-Improve LV function

48

Example set of d/c Rx in acute STEMI?

-Aspirin 100mg d
-Atenolol 25mg d
-Perindopril 2.5mg d
-Atorvastatin 20mg d
-Clopidogrel 75mg d
-Nitrolingual spray prn

49

What is the post hospital management of an AMI?

-Modify lifestyly: diet, exercise, quit smoking, LoW, EtOH.
-Modify cardiac RFx (DM, chol, HTN)
-Medications
-R/v at 1/12 then 6/12 (w/ rpt echo at 6/12)

50

What are the relative contraindications to thrombolysis?

-1. TIA last 6mo
-2. Oral anticoagulant therapy
-3. Pregnancy within 1 week post partum
-4. Non compressible punctures
-5. Traumatic resuscitation
-6. Refractory HTN (sBP >180)
-7. Advanced liver disease
-8. Infective endocarditis
-9. Active peptic ulcer