M103 T3 L7

Question 1

What are the three types of CVD?

Answer 1

CHD, CVD, PVD
Coronary heart disease
Cerebrovascular disease
Peripheral vascular disease

Question 2

What are the controllable risk factors for CHD?

Answer 2

Cigarette Smoking
Diabetes, obesity, high cholesterol
High bp

Question 3

What are the non-controllable risk factors for CHD?

Answer 3

Age / previous heart attack

Family history of premature coronary disease

Question 4

What are the clinical manifestations of IHD?

Answer 4

can be asymptomatic - silent ischaemia
stable angina, arrhythmias
acute coronary syndromes
NSTEMI, STEMI
HF, Sudden death

Question 5

What are two types of presenting factors in patients with acute coronary syndromes?

Answer 5

patients with unstable angina

patients who had heart attack or an acute myocardial infarction

Question 6

What are the two types of heart attack?

Answer 6

NSTEMI

STEMI

Question 7

What are the long term manifestations of IHD?

Answer 7

Heart failure
Arrhythmias
Sudden death

Question 8

What is the pathology behind stable and unstable angina?

Answer 8

due to a fixed stenosis / narrowing within one or more coronary artery is and then

Question 9

What is the pathology behind myocardial infarction and heart failure?

Answer 9

myocardial infarction - plaque rupture and thrombosis cause myocardial necrosis
heart failure - myocardial dysfunction due to infarction or ischaemia

Question 10

What is the pathology behind arrhythmia and sudden death?

Answer 10

arrhythmia - altered conduction due to ischaemia or infarction
sudden death - ventricular arrhythmia, asystole or massive myocardial infarction

Question 11

What are the three criteria for typical angina?

Answer 11

substernal chest discomfort
provoked by exertion or emotional stress
relieved by rest and/or nitrates within minutes

Question 12

What are the criteria for atypical angina?

Answer 12

meets two of the three criteria for typical angina

Question 13

What are the criteria for non-anginal chest pain?

Answer 13

lacks or meets only one of the three criteria for typical angina

Question 14

What are the first lines of treatment for angina relief?

Answer 14

short acting nitrate - tablet form or spray under tongue

beta blocker / calcium channel blocker

Question 15

In what conditions is the second line of treatment for angina relief administered?

Answer 15

if the patient is allergic / intolerant to the first line treatment or of the first line treatment
if first line treatment isn’t enough

Question 16

What is the next step in treatment for angina relief after the second line of treatment

Answer 16

refer the patient for an angiogram allows you to to visualise the heart arteries
can determine where the narrowing is and then physically treat them via stenting or bypass surgery

Question 17

What is the main difference between NSTEMIs and STEMIs?

Answer 17

the specific pattern of abnormality on the ECG is different - it determines how urgent treatment is

Question 18

What is the difference between patients with unstable angina and myocardial infarction?

Answer 18

all patients with acute myocardial infarction present with high levels of troponin which is measured in a blood test
if their troponin levels are elevated - heart attack

Question 19

Why does troponin in the blood indicate myocardial infarction?

Answer 19

troponin is only released into the blood stream following injury to the heart muscle
typically triponin levels can become elevated within three hours of heart attack and can remain elevated in the blood system for up to two weeks

Question 20

How does a STEMI present on an ECG?

Answer 20

ST elevation on ECG is a marker of complete coronary occlusion
the patient will have a completely blocked artery and will need emergency treatment to reopen this blockage

Question 21

How does an NSTEMI present on an ECG?

Answer 21

Incomplete occlusion is associated with ST depression, variable T wave abnormalities or with a normal ECG
indicative of unstable angina

Question 22

Following from plaque disruption, what does a thrombus result from?

Answer 22

Adherence, activation and aggregation of platelets
Thrombin and fibrin production via the coagulation cascade (and thrombin release from platelets)
Vasoactive molecules released from platelets which cause vasoconstriction

Question 23

What are the classical symptoms of ACS?

Answer 23

Discomfort / pain in the centre of the chest that lasts for more than a few minutes or recurs
Discomfort / pain radiating to other areas, e.g. left arm/jaw/back
Can occur at rest and/or with exertion
Not relieved immediately with sublingual GTN

Question 24

What are the three differences between ACS and stable angina symptoms?

Answer 24

the chest pain lasts a lot longer with ACS
not relieved immediately with sublingual GTN
can occur at rest and/or with exertion

Question 25

What symptoms of ACS do elderly or diabetic patients usually present with?

Answer 25

Breathlessness Nausea or vomiting Sweating and clamminess potentially no chest pain at all (especially in diabetics)

Question 26

Describe the immediate assessment of patients with suspected ACS

Answer 26

Patient history ECG - if high ST elevation - rushed off to have their artery fixed - angiogram Physical examination ``` Risk stratification Cardiac biomarkers (troponin) ```

Question 27

What are the therapeutic goals in ACS?

Answer 27

Restore coronary artery patency (STEMI) Limit myocardial necrosis (STEMI) Control symptoms

Question 28

What three types of therapy are used to manage ACS medically?

Answer 28

Anti-platelet therapy Anti-ischaemic therapy Secondary prevention therapy

Question 29

Which drugs are involved in anti-platelet therapy?

Answer 29

Aspirin | Clopidogrel or Prasugrel or Ticagrelor

Question 30

What treatment is involved in anti-ischaemic therapy?

Answer 30

Nitrates for pain

Question 31

What treatment is involved in secondary prevention therapy?

Answer 31

Statins, ACE inhibitors, Beta blockers | Smoking cessation , Lifestyle modification

Question 32

What is the importance of rapid treatment in STEMI?

Answer 32

Morphine and/or nitrates for pain relief Antiplatelet agents Primary angioplasty thrombolytics

Question 33

How is an emergency primary angioplasty performed?

Answer 33

in a catheter lab, under local anaesthetic through arteries take small thin tubes up to the heart under X-ray guidance inject dye into the arteries take some pictures to see what's blocked angioplasty to reopen the blockage

Question 34

What are the features of unstable angina?

Answer 34

occurs when the patient is at rest has a recent onset (less than two months 2 months) Recent acceleration / progression of angina symptoms Normal cardiac biomarkers are present (troponin)

Question 35

What criteria are used to identify high-risk patients?

Answer 35

``` Elderly, Recurrent chest pain, HF Elevated troponin levels Renal impairment Dynamic ST depression or T wave changes on ECG Haemodynamic instability Major arrhythmias ```

Question 36

What is the pathology behind unstable angina?

Answer 36

caused by the dynamic obstruction of the coronary artery due to a plaque rupture with superimposed thrombosis or spasm

Question 37

Which antiplatelet agents are used to treat NSTEMIs?

Answer 37

aspirin + clopidogrel

Question 38

What are examples of primary angioplasty treatments used to treat NSTEMIs?

Answer 38

balloons, stents

Question 39

What is the effect of primary angioplasty treatments when treating NSTEMIs?

Answer 39

the artery is mechanically reopened, restoring blood flow

Question 40

When are thrombolytics used to treat NSTEMIS?

Answer 40

when there is no access to primary angioplasty