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Year 5 Cardiology > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

what is the definition of ischaemic heart disease

A

reduced blood supply to cardiac muscle

causes angina pectoris

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2
Q

what are the different presentations of IHD

A 
-stable angina
ACS:
-unstable angina
-NSTEMI
-STEMI
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3
Q

what is the definition of myocardial infarction

A

cardiac muscle necrosis due to ischaemia

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4
Q

what is the aetiology of IHD

A 
O2 demand>O2 supply (angina)
BY:
-atherosclerosis (most common)
-spasms e.g. cocaine
-arteritis
-emboli
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5
Q

what is the aetiology of MI in IHD

A

sudden occlusion of coronary artery due to rupture of arthomatous plaque and thrombus formation

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6
Q

what is the pathophysiology of atherosclerosis

A

endothelial injury
migration of monocytes into subendoethlial space
differentiation into macrophages
accumulation of LDLs in macrophages in subendothelium forming foam cells
release of GFs
stimulates SM proliferation, production of collagen and proteoglycans
formation of atheromatous plaque

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7
Q

what are the risk factors associated with IHD

A 
male
DM
family history
HTN
hyperlipidaemia
smoking
previous history
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8
Q

what is the epidemiology of IHD

A

> 2% of population
more males than females
incidence is 5 per 1000 PA

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9
Q

what history is associated with stable angina

A

brought on by exertion

relieved by rest

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10
Q

what history is associated with ACS

A

acute onset chest pain
central heavy tight ‘gripping’ pain
radiation to L arm, neck, jaw, epigastrium
occurs at rest
increasing severity and frequency of previously stable angina

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11
Q

what would be the examination findings in stable angina

A

none

BUT observe for signs of risk factors

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12
Q

what would be the examination findings in ACS

A

may be no clinical signs
pale/sweating/low-grade pyrexia
radio-radial delay
arrhythmias
disturbances of BP
new heart murmurs (pansystolic murmur of mitral regurg)
indications of complications (acute HF/cardiogenic shock)

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13
Q

what would you find in cardiogenic shock

A

hypotension
cold peripheries
oliguria

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14
Q

what investigations would be performed in suspected IHD

A 
1. bloods
2 ECG
3 CXR
4 exercise ECG
5 radionuclide myocardial perfusion imaging
6 echo
7 pharmacologic stress testing
8 cardiac catheterisation/angiography
9 coronary calcium scoring
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15
Q

what bloods would you test in suspected IHD

A 
FBC/UEs/CRP/glucose/lipids
cardiac enzymes
amylase/TFTs
AST
LDH
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16
Q

what cardiac enzymes would you investigate in suspected IHD

A

CK-MB

troponin T/I

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17
Q

what is CK-MB

A

creatine kinase of the myocardium

released in response to myocardial damage

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18
Q

what is troponin T/I

A

very sensitive & specific markers of myocardial damage

increased 12H post myocardial damage

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19
Q

what are the other reasons for raised troponin T/I

A 
sepsis
tachycardia
PE
cardiac failure
stroke
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20
Q

why is it important to measure amylase in IHD

A

pancreatitis may mimic MI

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21
Q

what is AST

A

aspartate aminotransferase

increased (peaks) 24H post myocardial damage

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22
Q

what is LDH

A

lactate dehydrogenase

increased (peaks) 48H post myocardial damage

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23
Q

what would be the expected findings on an ECG in unstable angina/NSTEMI

A

ST depression
T wave inversion
Q waves can indicate old MI

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24
Q

what would be the expected findings on an ECG in a STEMI

A 
early
-hyperacute T waves
-ST elevation (>1mm in limb leads & >2mm in chest leads)
-new onset LBBB
late
-T inversion (hours)
-Q waves (days)
25
Q

what leads correspond to the inferior wall of the heart

A

II, III, aVF

26
Q

what leads correspond to the anterior wall of the heart

A

septum V1-2
apex V3-4
anterolateral V5-6

27
Q

what leads correspond to the lateral wall of the heart

A

I, aVL, V5-6

28
Q

what would a posterior infarct show on an ECG

A

tall R wave and ST depression in V1-3

29
Q

what would be the expected findings on a CXR in suspected IHD

A

signs of HF

  • alveolar oedema
  • kerley B-lines
  • cardiomegaly
  • diversion and dilation of upper lobe vessels
  • pleural effusion
30
Q

what is the use of an exercise ECG test in IHD

A

determines prognosis and management

31
Q

what are the indications for an exercise ECG test in suspected IHD

A

troponin negative ACS/stable angina

probable CAD

32
Q

why is it important to know if a patient is on digoxin before completing an exercise ECG test

A

produces a false positive result

33
Q

what is a positive test result in an exercise ECG

A

> 1mm horizontal/downward sloping ST depression

measured at 80ms after end of QRS

34
Q

what is a failed test in an exercise ECG

A

failure to reach 85% of predicted maximal HR (220-age)

no chest pain/ECG findings

35
Q

why should beta blockers be stopped prior to an exercise ECG test

A

reduces maximal HR

36
Q

what is radionuclide myocardial perfusion imaging

A

uses Tc-99m sestamini/tetrofosmin
performed under stress(exercise/psychological)/at rest
-stress testing: shows low uptake into ischaemic myocardium
-rest testing: used in patients with ACS with no previous MI

37
Q

what would an echo investigate in suspected IHD

A

LVEF

exercise/dobutamine stress echo may detect wall motion abnormalities

38
Q

what is pharmacologic stress testing

A

for patients who can’t exercise/exercise ECG inconclusive

imaging detects ischaemic myocardium

39
Q

what would be used to induce tachycardia in pharmacologic stress testing

A

dipyradamole
adenosine
dobutamine

40
Q

when is cardiac catheterisation/angiography used in suspected IHD

A

ACS with positive troponin
TIMI score of 5-7
high risk with stress testing

41
Q

what is coronary calcium scoring and when is it used in suspected IHD

A

a specialised CT
for presentation of atypical chest pain
for presentation of acute chest pain not clearly due to ischaemia

42
Q

what would be the management for stable angina

A

minimise cardiac risk factors
-control BP/hyperlipidaemia/diabetes
-stop smoking/more exercise/weight loss/healthier diet
-aspirin 75mg
immediate symptom relief
-GTN spray
long-term treatment
-beta-blockers(atenolol)/CCBs(verapamil)/nitrates
-dual therapy if monotherapy ineffective
PCI
-for localised stenosis in uncontrollable angina
-restenosis rate is 25% at 6 months
-drug eluting coronary stents reduce restenosis rates
CABP
-in severe cases (3-vessel disease)
-rates of MI & survival are similar to PCI

43
Q

what are the contraindications of beta-blockers in long-term treatment of IHD

A 
acute HF
cardiogenic shock
bradycardia
heart block
asthma
44
Q

what would be the management for unstable angina/NSTEMI

A

CCU( O2, IV access, monitor vital signs, serial ECG)
analgesia (GTN, morphine sulphate/diamorphine)
aspirin (300mg loading, 75mg maintenance indefinitely)
clopidogrel (300mg loading, 75mg maintenance for minimum 1yr in troponin positive)
LMWH (dalteparin)
beta-blockers (metoprolol)
glucose-insuline infusion if blood glucose>11mmol/L
consider GPIIb/IIIa inhibitors if patient:
-undergoing PCI
-at high risk of cardiac events (troponin positive)

45
Q

what is the mneumonic for treatment of heart attack

A

Morphine
Oxygen
Nitrates
Aspirin

46
Q

what would be the management for a STEMI

A

CCU
-O2, IV access, monitor vital signs, serial ECG
analgesia
-GTN, morphine sulphate/diamorphine
aspirin
-300mg loading, 75mg maintenance indefinitely
clopidogrel
-600mg loading with PCI, 300mg loading with thrombolysis+.75yrs, otherwise 75mg maintenance for minimum 1yr
-beta blocker

47
Q

what would be the management for a STEMI if undergoing primary PCI

A

IV heparin (+GPIIb/IIIa inhibitor)/antithrombin bivalirudin

48
Q

what is bivalirudin

A

reversible direct thrombin inhibitor

49
Q

what would be the management for a STEMI if undergoing thrombolysis

A

recombinant tissue plasminogen activator

IV heparin

50
Q

when would you use a glucose-insulin infusion in a STEMI

A

blood glucose>11mmol/L

51
Q

what is the secondary prevention for IHD

A 
antiplatelet agents
-aspirin
-clopidogrel
ACE inhibitors
beta-blockers
statins
control HTN, smoking, diabetes
52
Q

what advice would be given to someone with IHD

A

lifestyle changes

cannot drive for 1 month post MI

53
Q

when would a CABG be used in IHD patients

A

patients with left main stem/three vessel disease

54
Q

what are the complications associated with IHD

A

increased risk of MI/stroke/peripheral vascular disease

cardiac injury secondary to HF/+arrhythmias

55
Q

what are the early complications (24-72h) associated with MI

A 
death
cardiogenic shock
HF
ventricular arrhythmias
HB
pericarditis
thromboembolism
56
Q

what are the late complications associated with MI

A 
ventricular wall/septum rupture
valvular regurgitation
ventricular aneurysms
tamponande
dressler's syndrome (pericarditis)
thromboembolism
57
Q

what does the TIMI score estimate

A

estimates mortality in patients with unstable angina/NSTEMI

58
Q

what is the TIMI score

A 
1 >65yrs
2 known CAD (stenosis>50%)
3 aspirin use in past 7 days
4 severe angina (past 24h)
5 ST deviation >1mm
6 elevated troponin levels
7 >3 CAD risk factors
-HTN
-hyperlipidaemia
-family history
-diabetes
-smoking
59
Q

what is the killip classification of acute MI

A 
class I no evidence of HF
class II mild/moderate evidence of HF (HS3, crepitations

Year 5 Cardiology (42 decks)

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