Ischaemic Heart Disease And Atrial Fibrillation

Question 1

What is a MI ?

Answer 1

Necrosis of a section of myocardial tissue due to ischaemia ( an inadequate supply of blood to affected tissue ).

Question 2

What usually causes an MI ?

Answer 2

An atheromatous plaque that ruptures or erodes in a coronary artery causing a thrombus to form. This can partially or completely block the blood flow in the artery.

Question 3

What are some risk factors for a MI ?

Answer 3

Male sex
Advancing age
Obesity
Smoking
Hypertension
Physical inactivity
Hypercholesterolaemia
DM
Family history

Question 4

What are some complications of a MI ?

Answer 4

Heart failure
Stroke
Depression
Sudden death

Question 5

What lifestyle management should be given to prevent recurrence of a MI ?

Answer 5

Stop smoking
Cardioprotective diet : low salt, low sugar, wholegrain
Increase physical activity
Weight loss
Limit alcohol

Question 6

What medications should be started when someone has had an MI ?

Answer 6

ACEi
Aspirin + Clopidogrel
Beta blocker
Statin

Question 7

What indicates a MI ?

Answer 7

Detection of high troponin levels
Symptoms of ischaemia
ECG showing ST-T changes or new left bundle branch block
Development of pathological Q waves

Question 8

What are some differentials for an MI ?

Answer 8

Cardiac :
- pericarditis
- myocarditis
- mitral valve prolapse
- Aortic dissection

Pulmonary :
- PE

GI :
- peptic ulcer
- pancreatitis
- cholecystitis

Question 9

What is angina ?

Answer 9

A clinical syndrome of chest pain or pressure that accompanies periods of MI. It is usually aggravated by by activities which increase myocardial demand for oxygen.

Question 10

What are the clinical features of angina ?

Answer 10

Tight, dull or heavy discomfort often seen retrosternally or left side
Fatigue
Nausea

Question 11

What are some conditions which precipitate atherosclerosis ?

Answer 11

Hypertension
Hypercholesterolaemia
Smoking
Diabetes

Question 12

What are some differentials for angina ?

Answer 12

Aortic stenosis
Hypertrophic cardiomyopathy
Mitral valve prolapse
Aortic dissection
PE
GORD
Gastritis
Pancreatitis

Question 13

What investigations should be performed when suspecting angina ?

Answer 13

Blood tests
CXR
ECG

Question 14

What medication should be used for an acute attack of angina ?

Answer 14

Short acting nitrate

Question 15

What is the management of unstable angina ?

Answer 15

Aspirin and antithrombin therapy
Offer fondaparinux
Offer coronary angiography with follow on PCI within 72 hours of admission

Question 16

What is the management of chronic angina ?

Answer 16

Lifestyle measures - increase physical activity, stop smoking, increase food and veg, weight control.
Manage stress
GTN spray
Consider aspirin, ACEi
Offer statin and treatment for high blood pressure

Question 17

What is atrial fibrillation ?

Answer 17

A supraventricular tachyarrhythmia characterised by ineffective, chaotic, irregular and rapid atrial activity resulting in the deterioration of atrial mechanical function.

Question 18

What score should be used to assess stroke risk in patients with AFIB and when should it be used ?

Answer 18

CHA2DS2-VASc stroke risk score
Symptomatic or asymptomatic paroxysmal persistent or permanent atrial fibrillation
Atrial flutter
Continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm

Question 19

When should you offer an anticoagulant in AFIB and which one should you offer ?

Answer 19

The CHA2DS2-VASc score is 2 or above
Apixaban, dabigatran, edoxaban and rivaroxaban

Question 20

What should be offered if a DOAC is contra-indicated in AFIB ?

Answer 20

Vitamin K antagonist

Question 21

What is the primary pathologic change in AFIB ?

Answer 21

Progressive fibrosis of the atria which is primarily due to atrial dilation.

Question 22

What are some potential causes of AFIB ?

Answer 22

Hypertension
Cardiac valve disease
Coronary artery disease
Left ventricular systolic dysfunction
Thyrotoxicosis
Sepsis

Question 23

What are some features of paroxysmal AFIB ?

Answer 23

It is usually self terminating and recurrent
Episodes may last up to 7 days and after 48 hours the probability of spontaneous conversion is low and anticoagulation is required.
Often more asymptomatic

Question 24

What is persistent AFIB ?

Answer 24

Does not self terminate and lasts for more than 7 days or cardioversion is needed to restore sinus rhythm
Recurrent

Question 25

What are some clinical features of AFIB ?

Answer 25

Asymptomatic Palpitations Chest pain Hypotension Dyspnoea Dizziness / syncope

Question 26

What should an initial evaluation of AF involve ?

Answer 26

Determination of the European Heart rhythm association score Estimation of stroke risk Search for conditions associated with AF - hypertension Search for complications of arrhythmia - stroke

Question 27

What should be included in the physical exam into of an AFIB patient ?

Answer 27

BP HR Presence of a cardiac murmur Evidence of heart failure

Question 28

What score is used to assess bleeding risk in patients with AF ?

Answer 28

ORBIT bleeding risk score

Question 29

When should you offer monitoring and support to modify risk factors for bleeding ?

Answer 29

Uncontrolled hypertension Poor control of INR in patients on vit K antagonists Harmful alcohol consumption Reversible causes of anaemia Medications such as antiplatelets, SSRI’s and NSAIDs

Question 30

What is the principle investigation for AF ?

Answer 30

ECG and should be done in all patients whether symptomatic or not - irregular pulse 12 lead ECG

Question 31

What should be performed if paroxysmal AF is suspected and isn’t detected by standard ECG recording ?

Answer 31

A 24 hour ambulatory ECG monitor should be used

Question 32

Other than ECG what investigations should be performed when suspecting AF ?

Answer 32

FBC U & E Thyroid function test CXR Echocardiography

Question 33

What are the main goals of management of AF ?

Answer 33

Urgent control of the ventricular rate Restoration of sinus rhythm by drugs or electrical means Prevention of thromboembolic complications Prevention of recurrence

Question 34

What is DC cardioversion of AF ?

Answer 34

Requires a light general anaesthetic or sedation with IV diazepam The DC shock is synchronised with an R wave and presence of 2 or more consecutive P waves after shock delivery is considered an indication of success

Question 35

What are some non-drug management options of AF ?

Answer 35

DC cardioversion Pacemaker implantation Radio frequency ablation Surgical intervention

Question 36

What are the 3 aims in the drug treatment of AF ?

Answer 36

Control the ventricular rate Chemical cardioversion to sinus rhythm Prevention of thromboembolism

Question 37

what medications should be given for AF ?

Answer 37

Beta blocker or rate limiting CCB Anticoagulation - warfarin or DOAC

Question 38

What should be avoided in patients with paroxysmal AF ?

Answer 38

Alcohol and caffeine

Question 39

What are some complications of AF ?

Answer 39

Stroke Thromboembolism HF

Question 40

What follow up should be organised for patients with AF ?

Answer 40

Within 1 week of starting rate control meds have a follow up to assess if the patient is tolerating the drug and review symptoms, HR and BP. When on warfarin a patient should have their INR measured daily until it is within the desired range.

Question 41

How should i review a person with AF ?

Answer 41

Check symptoms Review medications Reassess the persons stroke risk using the CHA2DS2-VASc assessment tool and bleeding risk Assess cardiovascular risk Assess for complications or AF