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1

  • what is the Vascular supply to the heart and anatomy of the coronary arteries? And what are the associated areas which are served by what vessels 

Vascular supply to the heart (coronary arteries)
-The heart is supplied by the right and left coronary arterie s which arise from the ascending aorta
-The right coronary artery mainly supplies the right atrium and ventricle. It’s branches are:
oRight conus artery
oAnterior ventricular branches
(inc. marginal branch)
oPosterior ventricular branches
oPosterior descending artery
oAtrial branches
- The left coronary artery is larger & supplies most of the heart
and left atrium / ventricle. It has two main branches are:
o Anterior descending branch
o Circumflex artery

2

What is cardiac pain, what are the mechanisms?  

- Cardiac pain can be due to ischaemic cardiac disease or non-ischaemic cardiac disease.

- Examples of ischaemic causes for cardiac pain are stable angina, unstable angina and myocardial infarction.

- Examples of non-ischaemic cause m ms for cardiac pain include myocarditis, pericarditis or aortic dissection.

- In ischaemic cardiac disease, cardiac pain is felt due to the build-up of lactic acid (hence drop in pH) of the myocardium. (PICTURE 1) .

 

 

3

what are different mechansims of pain? (eg somatic vs visceral)

 

Pain is due to stimulation of specific nerve fibres to the brain by actual or potential tissue damage

There are three main types:

Visceral pain:-  Is caused by organs & transmitted by the autonomic nervous system.  Is poorly localised, dull/vague tenderness, may be colicy & patient tends to move around.

Parietal pain:- Sharp pain associated with inflammation of the parietal pleura.  Is well localised, sharp and the patient tends to lie still.

Referred pain:-  Pain felt at one location due to pathology at a different location.  Is due to structures that develop from the same embryonic segment or dermatome.

4

WHAT is  referred pain? (cardiac specific) 

Referred pain:  (PICTURE 2) 

- Refers to pain which is usually at a distance from its original source.

- Referred pain typically occurs because tissue in different parts of the body develop form the same embryonic dermatome.

●      An example of referred pain is that myocardial pain may be referred to the abdomen as hypogastric pain left jaw and arm

explanation detailed: 

 The cardiac general visceral sensory pain fibers follow the sympathetics back to the spinal cord and have their cell bodies located in thoracic dorsal root ganglia (. As a general rule, in the thorax and abdomen, general visceral afferent (GVA) pain fibers follow sympathetic fibers back to the same spinal cord segments that gave rise to the preganglionic sympathetic fibers. The central nervous system (CNS) perceives pain from the heart as coming from the somatic portion of the body supplied by the thoracic spinal cord segments 1-4. Classically the pain associated with a myocardial infarction is located in the mid or left side of the chest where the heart is actually located. The pain can radiate to the left side of the jaw and into the left arm

5

Explain the Haemodynamic effects of cardiac dysfunction, and  the pathogenesis of oedema/ raised JVP? 

If there is left ventricular dysfunction resulting in backpressure through the left atrium into the pulmonary system. Consequently, leading to right ventricular dysfunction and right atrial back pressure. The result of this will elevate the JVP and peripheral oedema (due to increased pressure and fluid in the systemic veins).  Alternatively, there could be right ventricular dysfunction resulting in the same consequences

Haemodynamic Effects of Cardiac Dysfunction (heart failure):

Pathogenesis of Oedema:  Oedema is excess of fluid in intercellular components of a tissue ® swelling

 In left-heart failure:

o   Left ventricle ineffective at pumping blood to body \ blood pools in pulmonary system ® increased fluid in pulmonary system ® pulmonary oedema

o   As fluid fills the alveoli, this reduces the effective lung volume available for respiration and patient becomes short of breath (dyspnoea

In right-heart failure:

o   Right ventricle ineffective at pumping blood to lungs \ blood pools in systemic veins ® increased intravenous pressure (hydrostatic pressure) ® increased fluid in legs ® swelling

  NB: Oedema in the legs can also be due to venous obstruction by a thrombus

 Raised JVP

  • Is a sign of right heart failure and gives an indication of right atrial pressure
  • Elevated systemic venous pressure causes distention of superior jugular vein

6

Explain the gnereral ECG changes in Myorcardial infaction?

 

Myocardial infarction can result in either a NSTEMI or STEMI episode.

  • NSTEMI account for about 30% and STEMI for the other 70% of all MI
  • NSTEMI occurs by developing a complete occlusion of a minor coronary artery or a partial occlusion of a major coronary artery previously affected by atherosclerosis - this causes partial thickness damage of the heart muscle
  • STEMI occurs by developing complete occlusion of a major coronary artery - causing full thickness damage of the heart muscle

 

 

The usual ECG findings of a NSTEMI are ST depression or T wave inversion - there is NO ST elevation and later does not progress to a Q wave

  • ST elevation & T wave invesion indicates proximal occlusion of major coronary artery (STEMI)

Acute anterior (septal) infarct

ST elevation in leads V2 to V6

Acute inferior infarct

ST elevation in leads II, VIII, AVF

Acute lateral infarct

ST elevation in leads I, II, AVL, V5, V6

NB: Pericarditis (not MI)

ST elevation and PR depression

 

 

7

what features would be seen on an Anterior MI ECG?

Anterior Myocardial Infarction

  • results from occlusion of the LAD
  • carries the worst prognosis of all infarct locations, mostly due to larger infarct size
  • In Anterior STEMI
    • ST segment elevation and Q wave formation in the precordial leads (V1-V6) + high lateral leads (I and aVL)
    • Reciprocal ST depression in the inferior leads (mainly III and aVF)
    • Septal area illustrated by V1-V2
    • Anterior portion by V2-V5 
    • Anteroseptal = V1-V4
    • V5 and 6 will be involved in an extensive Anterior STEMI and

8

what ECG changes would be seen in an inferior STEMI

 

Inferior STEMI

  • more favourable prognosis than anterior myocardial infarction
  • block to the RAD most commonly (80%), less commonly left circumflex, occasionally all three
  • up to 20% of patients with inferior STEMI will develop significant bradycardia due to second or third degree heart block
  • On an ECG inferior STEMI
  • ST elevation in II, III, aVF
  • Progressive development of Q waves in II, III, aVF
  • Reciprocal ST depression in aVL 

9

what ECG changes would be seen in an lateral MI?

 

Lateral STEMI

  • the lateral wall of the LV is supplied by branches off the LAD and the left circumflex
  • Lateral STEMI on an ECG
    • ST elevation in the lateral leads (I, aVL, V5-V6)
    • Reciprocal depression in the inferior leads (III, aVF)

10

 What causes troponin and enzyme levels to change?

 

  • Cardiac biomarkers should be measured in all patients who present with chest discomfort consistent with ACS. Elevations of cardiac enzyme levels should be interpreted in the context of clinical and ECG findings.
  • Cardiac troponins T and I are the preferred markers for myocardial injury as they have the highest sensitivities and specifities for the diagnosis of acute MI.
  • Troponin is a protein released from myocytes when irreversible myocardial damage occurs. It is highly specific to cardiac tissue and accurately diagnoses MI with a history of ischaemic chest pain or ECG changes reflecting ischaemia.
  • Cardiac troponin level is dependent on infarct size, thus providing an indicator for the prognosis following an infarction.
  • Serum levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours and return to baseline over 5-14 days.
  • Troponin levels should be measured at presentation and again 10-12 hours after the onset of symptoms.
  • May not be detectable for 6 hours after the onset of myocardial cell injury. The most sensitive early marker for MI is myoglobin. Myoglobin is found in cardiac and skeletal muscle. It is released more rapidly from infarcted myocardium than troponin and CK-MB and may be detected as early as 2 hours after an acute MI. High sensitivity but poor specifity.
  • Myocardial muscle creatine kinase (CK-MB) is found mainly in the heart. Levels increase within 3-12 hours of onset of chest pain, reach peak values within 24 hours and return to baseline after 48-72 hours. Sensitivity and specificity are not as high as for troponin levels.
  • Troponin levels may also be elevated in patients with myocarditis, aortic dissection, congestive heart failure, sepsis, acute PE and CKD.

11

What is pericarditiis and the ECG changes seen with it?

Pericarditis

  • Inflammation of the pericardium produces characteristic chest pain (retrosternal, pleuritic, worse on lying flat, relieved by sitting forward), tachycardia and dyspnoea
  • there may be an associated pericardial friction rub or evidence of a pericardial effusion
  • Wide ST segment changes occur due to involvement of the underlying epicardium

ECG findings

  • Widespread concave ST elevation and PR depression through most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-V6)
  • reciprocal ST depression and PR elevation in lead aVR
  • sinus tachycardia is also common in acute pericarditis due to pain and or pericardial effusion

Stages of Pericarditis

  • Stage 1 - widespread STE and PR depression with reciprocal changes in aVR
  • Stage 2- normalisation of ST changes, generalised T wave flattening (1 to 3 weeks)
  • Stage 3- flattened T waves become inverted ( 3 to several weeks)
  • Stage 4- ECG returns to normal

 

12

what questions would you ask someone with acute chest pain? (history) 

Should cover basic history (presenting complaint, history of presenting complaint, etc. etc.)

  • Questions for taking a pain history include: NILDOCARF
  • Nature of the pain (tight, crushing, etc.)
  • Intensity of the pain (on scale of 1 to 10)
  • Location of the pain (get patient to point)
  • Duration of the pain
  • Onset (what was the patient doing when it started)
  • Concomitant factors (any other symptoms)
  • Aggrevating factors (what makes it worse)
  • Relieving factors (what makes it better)
  • Frequency
  • Note: atypical chest pain presentations –
  • Some patients will only present with breathlessness
  • Men are more likely to rate pain on a lower scale than women
  • Women are more likely (compared to men)  not to feel chest pain during a heart attack but rather higher rates of ‘atypical presentations’ (inc. vomiting, fatigue, back pain) and have increased psychological causes (eg. panic attack)

Extened history (full history)

  • Do you identify as an Aboriginal or Torres Strait Islander?
  • HPC
    • What were you doing when it started? (exertional/ non-exertional)
    • Describe the pain (character)?
      • Is it sharp/ dull/ burning/ heavy or tight?
    • Does the pain radiate anywhere?
      • Neck, arm or back?
    • How painful is it from a  scale of 1/10
    • How long did it last for?
    • Did you have any sweating, palpitations, SOB, dizziness, fainting, nausea or vomiting?
    • Have you have this before? Have you had MI/ angina before?
  • pMHx
    • Have you had angina/ heart attack before?
    • HTN/ diabetes/ dyslipidaemia/ peripheral vascular disease
    • Other relevant past medical history.
  • Allergies: do you have any allergies?
  • Medications
    • Do you take any regular medications?
  • Immunisations:
    • Are you up to date with your immunisations?
  • Family history
    • Any family history of cardiac/ respiratory problems?
    • Other family history
  • Social history
    • Do you smoke/ drink / exercise?
    • What is your diet like? Does it contain lots of fat or is it generally healthy?
    • What do you do for a living?
    • What do you do in your free time?
    • Who do you live with?
    • Do you have any children?
  • Have you travelled anywhere recently?
  • System’s review
    • CVS
      • Are you SOB on exertion?
      • Have you ever woken up at night short of breath?
      • Can you lie flat w/o feeling breathless?
      • Have you had swelling of your ankles?
      • Have you had palpitations?
      • Do you have pain in your legs on exercise?
      • Do you ever get cold/blue hands/ feet?
      • Have you ever had ARF, heart attack or high BP?
      • Do you have any breathing difficulties? cough
    • Respiratory
      • SOB? cough? sputum? blood? wheezing? fevers? night sweats?
      • Have you ever had pneumonia or Tb?
      •  
    • GIT
      • Do you have indigestion? heartburn? difficulty swallowing?
      • Any nausea/ vomitting? or vomitted blood?
      • Any pain or discomfort in your tummy?
    • MSK
      • Do you have painful/ stiff joints?
      • Any inujries to the chest recetly?
    • Neurological and mental state
      • Have you had any fainting episodes, dizziness?
      • Have you ever had a stroke?
      • Do you feel anxious?
      • Have you had weakness in you arms or legs?

 

13

List the clinical features fo ACS: 

 

3 conditions make up the term ACS; Unstable angina, MI & Sudden Cardiac Death.

The signs and symptoms of acute coronary syndrome, which usually begin abruptly, include the following:

  1. ·   Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning
  2.  Pain radiating from the chest to the shoulders, arms, upper abdomen, back, neck or jaw
  3. ·Nausea or vomiting
  4.   Indigestion
  5.  Shortness of breath (dyspnoea)
  6.  Sudden, heavy sweating (diaphoresis)
  7. ·   Light-headedness, dizziness or fainting (LOC)
  8.  Unusual or unexplained fatigue
  9.   Feeling restless or apprehensive

14

 

How do you make a diagnosis of ACS? what would be initial and confirmatory investigations?

laboratory

FBC

  • UEC/ glucose (especially K)
  • Cardiac troponin I
  • Normal levels are considered vary according to the exact assay that is being used
  • In general terms a normal level is considered to be < 99th percentile for the assay
  • may persist for 5-14 days post infarction
  • Reinfarction can also be assessed via troponin levels (CK/CKMB is now obsolete and not required)
  • Rising versus falling levels
  • For the vast majority of patients being investigated for possible MI, a rising pattern is suggestive of the diagnosis of MI
  • In patients who present late following MI, troponin elevations may have already peaked and in this context, a falling troponin pattern is significant
  • Note that all troponin assays, regardless of their detection sensitivity do not rule out unstable angina or stable coronary ischemia

Clinical management decisions should not be based solely on troponin levels, but on thorough investigation and risk assessment that includes detailed clinical assessment, observation, repeated ECG tests, and where available functional testing

An initial troponin level should be done on all cases of suspected ACS with a second level done at 6 hours (sensitive assay) or 3 hours (highly sensitive assay) from the onset of the chest pain.

Note that some patients that fit specific low risk stratification criteria may be suitable for validated accelerated diagnostic pathways.

ECG

  • All patients who present with a suspected ACS must have an ECG within 10 minutes of first acute clinical contact
  • A clinician with ECG expertise should review the ECG
  • The immediate decision pathway then involves the ECG stratification of STEMI, from NSTEACS
  • STEMI minimum criteria:STEMI is defined as presentation with clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
  • ≥ 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
  •  ≥ 1.5 mm ST elevation in V2-3 in women
  • ≥ 1 mm ST elevation in other leads
  • New LBBB (LBBB should be considered new unless there is evidence otherwise)
  • Findings in ACS
  • may be normal
  • classic changes in acute myocardial infarction
  • peaked T waves with ST elevation
  • gradual loss of R wave
  • development of pathological Q wave and TWI
  • anatomical localisation of ST elevation
  • Anteroseptal = LAD
  • Anterolateral = Cx
  • Inferior = RCA
  • Posterior = Cx or PDA (off RCA)
  • Minimal S-T changes can be difficult to interpret, especially in those with pre-existing CAD or other significant CVS disease. In such cases:
  • Comparison with old ECGs will be useful
  • Modified Sgarbossa criteria can help if LBBB or paced:
  • concordant ST elevation of > 1mm
  • concordant ST depression of > 1mm in V1, V2 or V3
  • discordant ST elevation of > 5mm
  • In cases of LBBB urgent echocardiography may be useful, if readily available, to detect wall motion abnormalities (suggesting myocardial ischaemia) and hence assist in decision making
  • CXR

This should not be allowed to delay any treatment measures, especially reperfusion therapies.

If an x-ray is done this should be in the Resus bay, except for stable low risk patients who may be suitable to leave the department for their x-ray, this will need to be judged on a case by case basis.

Look for cardiomegaly, cardiac failure and differentials of chest pain (e.g. PE, pneumonia, pneumothorax, esophageal rupture, aortic dissection)

Echocardiography (not a routine test in ACS, but may be considered on an urgent basis in selected cases)

Confirmation of wall motion abnormalities when the diagnosis of ACS is unclear (pericarditis or myocarditis is being considered for example or in cases of LBBB)

Cardiogenic shock

Inferior infarction where evidence of right ventricular infarction is being sort

If secondary complications are suspected, such as cardiac tamponade or valvular disruption

Coronary Angiography

This is the definitive investigation for any patient with a STEMI who is to undergo a PCI

Patients with high or very high risk NSTEACS should be referred to cardiology urgently for consideration of a urgent coronary angiogram.

15

Explain the basic management principles of  a patient with an acute ACS? 

STEMI MANAGEMENT:

Initial management

  • All patients must be triaged to a monitored resuscitation bay (ABC)
  • IV access, and blood tests taken
  • Oxygen therapy if hypoxic
  • Analgesia- opioids; morphine, fentanyl
  • Anti-emetic as required
  • Aspirin as soon as you are concerned

       

Further management

  • GTN if pain not controlled by opioids
  • Anti-Platelet therapy as required
  • Heparin
  • Reperfusion if patients present whiten 12 hours of symptom onset
  • Surgical interventions according to local hospital practice
  • Thrombolysis

 

NSTEACS MANAGMNET:

Non-ST elevation acute coronary syndrome, and includes non-STEMI and unstable angina

 

Initial management

  • All patients must be triaged to a monitored resuscitation bay
  • IV access, and blood tests taken
  • Oxygen therapy if indicated
  • Analgesia: Nitrates, Opiates
  • Anti-emetic as required

 

Depending on the risk stratification level of patient also consider

  • Anti-platelet therapy
  • anticoagulation
  • Repercussion therapy

16

What are various reasons for atypical chest pain?

 

Differential diagnosis

Clinical presentation

Angina

Tight or heavy

Onset predictable with exertion

Moderate pain or discomfort

Relieved by rest

Relieved rapidly by nitrates

Not positional

Not affected by respiration

No sweating

Myocardial infarction (ACS)

Onset at rest

Central chest pain

Subacute onset (minutes)

Severe pain

Sweating

Anxiety (angor)

No relief with nitrates

Associated symptoms (nausea and vomiting)

Myocardial ischemia

Exertional

Occurs with exertion

Brief episodes

Diffuse

No chest wall tenderness ( only discriminates between infarction and chest wall pain)

Aortic dissection

Radiates to the back

Instantaneous onset

Very severe pain, tearing quality

Chest wall pain

Positional

Often worse at rest

Prolonged

Localised

Chest wall tenderness

Pericarditis or Pleurisy

Sharp or stabbing

Not exertional

Present at rest

Unaffected by nitrates

Worse supine (pericarditis)

Worse with respiration

Pericardial or pleural rub 

Oesophageal (acid) reflux pain

Burning

Not exertional

Present at rest

Unaffected unless spasm

Onset may be when supine

Unaffected by respiration

The approach to non-traumatic chest pain requires the early recognition and exclusion of potential life threats, then further consideration of other causes.

Causes

Potentially life-threatening causes of chest pain

Cardiovascular

  • Acute coronary syndromes (STE-ACS and NSTE-ACS)
  • Aortic dissection
  • Myocarditis (most common cause of sudden death in the young)
  • Pericarditis
  • Pulmonary embolism

Other

  • Tension pneumothorax
  • Acute chest syndrome (in sickle cell disease)
  • Boerhaave’s syndrome (perforated esophagus)
  • Common non-life-threatening causes of chest pain
  • Gastrointestinal
  • Biliary colic
  • Gastroesophageal reflux
  • Peptic ulcer disease
  • Pulmonary
  • Pneumonia
  • Pleurisy
  • Chest wall syndromes
  • Musculoskeletal pain
  • Costochondritis
  • Thoracic radiculopathy
  • Texidor’s twinge (precordial catch syndrome)

 

 

 

 

 

 

17

How is ACS best managed in a rural setting? What facilities would exist locally e.g. Ravenshoe, Hughendon or Emerald?  

Fibrinolytic Therapy Fibrinolytic therapy is more widely available and is beneficial in a wider range of patients who may not have access to PPCI38-40. Fibrinolytic therapy can be safely given by a trained paramedic, nurse or physician using established protocols41-45. (LOE I) The efficacy is greatest given the first three hours of the onset of symptoms. Without timely access to primary PPCI, patients with symptoms of ACS and ECG evidence of ST elevation infarction or true new bundle branch block or true posterior infarction should be treated with fibrinolytic therapy as soon as possible. In patients presenting early after the onset of chest pain (<1-2 hours) and in certain clinical subsets (<65 years-of-age, anterior STEMI), prehospital fibrinolysis may offer similar outcomes compared to PPCI20,46,47. (LOE II) There are a number of contraindications to fibrinolysis that health care practitioners need to be well aware of (see Table 1)1,48. In addition, the older patients are a difficult patient group. They have a high absolute risk of death from their STEMI, have an increased absolute benefit from fibrinolytic therapy but the risk of intracranial bleeding from fibrinolysis is also higher. This is increased in the presence of systolic hypertension of over 180 mmHg. The benefits of fibrinolytic therapy are less impressive in areas of infarction other than an anterior STEMI location.

18

Initial management of ACS ?

ABCDE, defibrillator at hand, quick history and examination, ECG and monitor,  oxygen [not essential], iv access & key bloods taken, aspirin, GTN and analgesia and organize urgent transfer to a cardiac unit, etc. 

19

What is Acute percutaneous coronary intervention [PCI? angiography, angioplasty, stenting]; and stenting, thrombolysis [if immediate PCI unavailable] , urgent surgery, anticoagulation [short term and long term?

angiography;radiography of lymph/blood vessels with the use of radio-opaque substances.

angioplasty; threading a catheter through a peripheral vessel to the stenosed artery. once in the correct location a small balloon is inflated to open the narrowed artery then the balloon is deflated and rermoved.

stenting; uses angioplasty but with the addition of a stent, which is a net like device for holding the artery open once the balloon is removed.

thrombolysis;dissolving of a clot using drugs to re-open the occluded vessel

surgery; coronary artery bypass graft (CABG) using a peripheral vessel (such as the great saphenous vein) to bypass the occlusion by attaching the harvested vessel to the occluded vessel both behind and in front of the occlusion.

anticoagulant; a drug that prevents the clotting of blood specifically by targeting the clotting cascade. (short term pre-operative, long term (warfarin--> for patients with increased CVS risk ect) 

20

What is the process of Discharge management and cardiac rehabilitation in a patient with ACS?

Discharge management

Patients with ACS are at high risk of further cardiovascular events and death. For long term management a medicines management, chest pain action plan and a CVD risk reduction program are recommended

Medications

  • Antiplatelets
    • Aspirin: low dose following an ACS event and continue for life, unless there is a past history of dyspepsia
    • Clopidogrel: commence additional antithrombotic therapy in combination with low dose aspirin for stent recipients (12 months), patients being managed medically following STEMI, not recommended for low risk ACS patients
  • Beta blockers
    • maintain oral beta blocker therapy in most patients following an ACS event and continue for life
  • ACE inhibitors/angiotensin II receptor antagonist
    • ACE inhibitors should be given early after an ACS event and continued indefinitely
  • Statins
    • Initiate statin therapy in all patients and continue for life regardless of fasting blood lipid level
    • consider other lipid modifying agent if tolerated to statin
  • Short acting Nitrate
    • Ensure a short acting nitrate is included as part of the chest pain

Chest Pain action plan

  • discuss the warning signs of a heart attack and an immediate plan of action, including the use of short acting nitrates
  • self administration of aspirin, unless contraindicated
  • instructions to call an ambulance if chest pain is not relieved after 10 minutes

Identify and Discuss risk factors

  • provide patients with a self management plan before discharge
  • plan should include advice on lifestyle changes including
  • quitting smoking
  • good nutrition
  • moderate alcohol intake
  • regular physical activity
  • weight management
  • All patients should be referred to a cardiac  rehabilitation program 

Cardiac Rehabilitation Program (Australian Heart Foundation)

  • Maximise physical, psychological and social functioning to enable people with cardiac disease to lead fulfilling lives with confidence
  • Introduce and encourage behaviours that may minimise the risk of further cardiac events and conditions
  • Facilitate and shorten the period of recover after an acute cardiac event 

Main elements of outpatient cardiac rehab

  • Assessment and regular review - attention to physical, psychological and social
  • Low or moderate intensity physical activity
  • Education, discussion and counselling

21

explain Diagnostic Imaging: normal anatomy, coronary angiography, nuclear scanning techniques, echocardiography and exercise echo, CT and MRI cardiac imaging

Coronary angiography

  • Is a procedure that uses contrast dye, usually containing iodine and X-ray pictures to detect blockages in the coronary arteries that are caused by plaque build up. It is an important test used when your doctor suspects or knows that you have coronary heart disease.
  • During the procedure, the patient is given a local anaesthetic and then a catheter is put into an artery in your groin, or at the inside of your elbow or near your wrist. The catheter is moved up the inside of your artery until it reaches your heart. A dye is then injected into your coronary arteries and X-rays are taken. The X-ray image gives detailed information about the state of your heart and coronary arteries.

Nuclear scanning techniques

  • Cardiac nuclear medicine is useful in diagnosing and assessing coronary artery disease. It is also used to evaluate cardiomyopathy and identify possible damage to the heart from chemotherapy or radiotherapy.
  • Depending on the type of nuclear medicine exam, the radiotracer is either injected into the body, swallowed or inhaled as a gas and eventually accumulates in the organ or area of the body being examined. Radioactive emissions from the radiotracer are detected by a special camera or imaging device that produces pictures and provides molecular information.
  • This imaging test can detect if blood is not flowing to parts of the heart and can diagnose coronary heart disease. It also can check for damaged or dead heart muscle tissue, possibly from a previous heart attack, and assess how well your heart pumps blood to your body.
  • Two sets of pictures taken - at rest and following exercise/stress test

Echocardiography

  • Ultrasound examination of the heart - high frequency sounds waves are used to create a moving picture of the heart. Uses standard 2D, 3D and Doppler ultrasound to create images of the heart. Routinely used in the diagnosis, management and follow up of patients with any suspected or known heart diseases. It can provide a variety of information including the size and shape of the heart (internal chamber quantification), pumping capacity, and the location and extent of any tissue damage. Can also provide estimates of heart function such as calculation of cardiac output, ejection function and diastolic function (how well the heart relaxes). Biggest advantage is its non invasive and has no known risks or side effects. Transthoracic and transesophageal types.
  • Stress echo - assesses the wall motion in response to physical stress. First, images are taken at rest to acquire a baseline of the patient’s wall motion at a resting heart rate. The patient then increases their HR to the target HR, or 85% of MHR (treadmill/exercise). Finally, images of the heart are taken at stress to assess wall motion at peak HR. A stress echo assesses wall motion of the heart; it does not, however, create an image of the coronary arteries directly. Ischemia of one or more coronary arteries could cause a wall motion abnormality, which could indicate coronary artery disease.

CT

  • Imaging test that uses X-rays to take many detailed pictures of your heart and its blood vessels. Computers can combine these pictures to create a three-dimensional model of the whole heart. This imaging test can help doctors detect or evaluate coronary heart disease, calcium buildup in the coronary arteries, problems with the aorta, problems with heart function and valves, and pericardial disease.
  • It also may be used to monitor the results of coronary artery bypass grafting or to follow up on abnormal findings from earlier chest x rays.
  • Before the test, a contrast dye, often iodine, may be injected into a vein in your arm. This contrast dye highlights your blood vessels and creates clearer pictures.

MRI

  • Uses a magnetic field, radio waves and a computer to produce detailed pictures of the structures within the heart.
  • Can provide detailed information on the type and severity of heart disease to help your doctor decide the best way to treat heart problems such as coronary heart disease, heart valve problems, pericarditis, cardiac tumors, or damage from a heart attack.
  • Does not use ionising radiation.

22

Explain in   Brief review of concepts of primordial prevention, primary prevention, secondary prevention and tertiary prevention-  in CVS

Primordial: prevention of ACS risk factors themselves, beginning with change in social and environmental conditions in which these factors are observed to develop, and continuing for high risk children, adolescents and young adults. (e.g. community-based policies on smoking cessation & eating a balanced diet – for kids)

 

Primary: Smoking cessation, balanced & nutritious diet from all 5 food groups, ample amount of physical activity, limit alcohol intake to guidelines & limit sugar/salt intake.

 

Secondary: Anticoagulant/antiplatelet therapy. Moreover, adjunctive therapies (i.e. B-Blockers, statins, anti-hypertensives), are important in secondary prevention to reduce the impact of risk factors of ACS. Lifestyle modifications on top of this is essential also.

 

Tertiary: coronary angioplasty/PCI – to prevent further deterioration of the disease. Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque build-up)

23

WHat is needed to determine absolute CVD risk?

Cardiovascular risk calculator à http://www.cvdcheck.org.au/

-          Uses patient’s age, sex, systolic blood pressure, smoking status, total cholesterol, HDL cholesterol, diabetes & ECG LVH to determine patient’s risk of developing a CVD in next 5 years.

24

What is the role of population screening for risk factors in clinical settings? (benefits), and how ir CVD risk assessment calculated and why is it important?

Benefits of population screening include:

-          Early detection and management of risk factors è HEALTH PROMOTION

-          Often risk factors are associated with other conditions (ie. type 2 diabetes) so help prevent all

-          Increased community awareness about condition

-          Cost-effective for healthcare system

  • Absolute CVD risk assessment combines risk factors to calculate the probability that an individual will develop a cardiovascular event (eg myocardial infarction, stroke) or other vascular disease within a specified time frame (usually five years).
  • Absolute CVD risk assessment should be conducted at least every two years in all adults aged >45 years who are not known to have CVD or to be at clinically determined high risk (B).
  • This calculation requires information on the patient’s age, sex, smoking status, total and high-density lipoprotein-cholesterol (HDL–C), systolic blood pressure (SBP) and whether the patient is known to have diabetes or left ventricular hypertrophy (LVH). In adults at low absolute CVD risk, blood test results within five years may be used for review of absolute CVD risk unless there are reasons to the contrary.
  • Adults >74 years of age may have their absolute CVD risk assessed with age entered as 74 years. This is likely to underestimate five-year risk but will give an estimate of minimum risk.
  • Patients with a family history of premature CVD (in a first-degree relative – men aged <55 years, women aged <65 years) or obesity (body mass index [BMI] above 30 kg/m2 or more) may be at greater risk. Similarly, patients with depression and atrial fibrillation (AF) may also be at increased risk.

25

 How do we change people's behaviour / lifestyle to prevent lifestyle diseases? Health Promotion?

  • motivational interviewing 
  • explain significance and importance of lifestyle chancges (SNAP) 
  • Give verbal and written lifestyles prescription 
  • use other agenecies (such as the hear foundation) to employ more knowlegde into the patient abnd understanding of risk factors 
  • give goals and monitor changes (diary) 

Prevention of CVD

Primary Prevention

  • Weight management
  • Diet/lipid management
  • BP management
  • Stop smoking
  • Exercise
  • Know family history

Secondary Prevention

  • Screening for CVD*
  • Diagnosis & assessment
  • Review for other risk factors (eg. high BP, high cholesterol, etc.)

Tertiary Prevention

  • Initiate therapy
  • Monitoring

*Benefits of population screening include:

  • Early detection and management of risk factors è HEALTH PROMOTION
  • Often risk factors are associated with other conditions (ie. type 2 diabetes) so help prevent all
  • Increased community awareness about condition
  • Cost-effective for healthcare system

26

How do we know that research is valid? What is strength of evidence? (EBM)?

Strength of Evidence –

When considering research and how effective a particular treatment is, there are 5 main categories used to assess ‘strength of evidence’.  These are:

I

Strong evidence from at least 1 systematic review of multiple well-designed randomised control trials.

II

Strong evidence from at least 1 properly designed randomised control trial of appropriate size

III

Evidence from well designed trials without randomisation, single group pre-post, cohort, time series or matched case-controlled studies

IV

Evidence from well-designed nonexperimental studies from more than 1 centre or research group

V

Opinions of respected authorities, based on clinical evidence, descriptive studies or report of expert committees

 

Research Study Types -

Randomised

When the people in the two control groups are put there by random.  This is to account for confounding factors.

Double-blind

When neither the people running the experiment nor the people in the control groups know which ‘group’ they are in.  Eg. one group takes real tablet and other takes placebo but neither know which.

Controlled

The experiment separates people into two groups (experimental group and control group).  The control group is practically identical to the experimental group, except for the single variable of interest whose effect is being tested.

Cohort

Look at a group of people with exposure & a group of people without exposure and see who had particular outcome

Case control

Look at a group of people with outcome & a group of people without the outcome and see who had a particular exposure

Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information --> best resources and knowledge for best patient outcomes 

 

 

 

27

Outline the principles of evidence based medicine.

1) knowledge and skills  and experience 

2) patient values and principles 

3) best avaliable evidence 

4) to make the best clincial descison 

 

28

What steps are necessary to make sure Ben can make a properly informed decision to proceed with any further warranted investigations?

●Informed consent is an individual’s voluntary decision about medical care which is made with knowledge and understanding of the benefits and risks involved.

●Most visible way that the health system ensures patient autonomy. Underscores how important it is for a doctor to have thorough knowledge of the benefits and risks of any treatments/interventions (i.e. ‘duty of disclosure’ or ‘appropriate disclosure’).

●How to ensure patients understand? Use plain language, repeat the information, reinforce key issues, use an interpreter if needed, draw diagrams, allow adequate time, check for understanding, offer second opinions.

●Consent can be withdrawn at any time.

●There are 3 elements of informed consent:

●1. Threshold elements

○·      Competence to make a decision.

●2. Information elements

○·      Disclosure of information - information provided about what is going to happen and the possible consequences.

○·      Understanding of information - information must be provided in a manner the patient can understand. As much depth as a reasonable person would want to understand. Understanding needs to be confirmed.

●3. Consent elements

○·      Consent needs to be voluntary and not subject to coercion.

○·       The patient needs to give authorisation in some way (e.g. signing a consent form or verbal consent).

●Factors impacting informed consent:

●Elderly patients (old age).

●Patients with below average IQ/low education.

●Impaired cognitive function

●An external locus of control (believe their decisions and life are controlled by factors they cannot influence such as the environment, other people or a higher power).

Cultural beliefs and traditions.

Language barriers/medical terminology

Time constraints on patient/physician

29

Are there complications he should know about? E.g. sudden death, arrhythmias, local bleeding etc?

  • Assuming he has IHD:
    • Cardiac dysfunction → mural thrombi that can cause further ischaemic episodes
    • Arrhythmias especially atrial fibrillation
    • Ruptured myocardium- fatal complication
    • Pericarditis
    • Papillary rupture, mitral regurgitation, pulmonary oedema

30

What is particular about this patient? E.g. education, language, culture, understanding.?

 

On examination, the patient was identified as being sweaty, anxious, borderline febrile with elevated blood pressure and BMI (obese). Dual heart sounds were heard with no abnormal or additional sounds upon precordial auscultation. His chest was clear with equal air entry and vesicular breath sounds, and palpation of abdomen revealed no tenderness. A particularly key feature in the case is that the patient stated he ‘felt fluey’ for the last 3 days prior to the bouts of chest pain that occurred. This opens diagnostics up to potential infective cardiac causes - i.e. infective endocarditis, viral myocarditis. Furthermore, the possibility of a respiratory infection like a LRTI such as pneumonia may also now be proposed as a possible differential in this case due to this recent Hx. of malaise.

education low? different culture may have lower understanding of medical litreacy

 

31

 

Who else needs to be involved in the decision? Enid and the rest of the family? 

 

The clinician who care for Ben should discuss with him the extent to which he wishes to involve his family in decisions concerning his health. If the patient desires a shared decision making style with family, clinicians can encourage patients to discuss this desire with their family or can facilitate this discussion during appointments in which the patient involves family. If a family member fears being blamed for providing inadequate care by other family members, this can be discussed to see if the patient would like to discuss his wishes with other family members as a way of avoiding this conflict.

32

What else does he need? – time to think etc

Access to defibrillator at home or implant cardiac defibrillator

·       Plan for Lifestyle changes that will reduce risk of CHD such as smoking cessation, nutrition, alcohol, physical activity and weight management

·       Action plan with clear instruction to patients and carers

·       Assessment and documentation of advance care/palliative care needs

·       Management for depression/anxiety and stress

33

o How will you know he understands?

 

  • ask the patient to re explain things about his condition and lifestyle factors that need to be changed 
  • use laymen terms so the patient understands 
  • explain the usuage of each medication to the patient and what they are targetting, (dose, frequency) and quiz the patient about this 
  •  

34

Previous medical consultations may compromise your medical treatment‐patient compliance/second opinion/patients understanding of the seriousness of their medical condition. How do you deal with this?

  • give extra adivce on compliance and make a diary for the patient 
  • explain the seriousness of the medical condition and the importance of correct treatment and compliance and consequences if pateint fails to comply
  • keep frequent visits to check up on patient 
  • employ family memebers as reinforces to assist lifestyle changes and assist in patient management 

35

Can you be certain he is not being rushed or coerced into a decision by you or others?

No, you can never be certain, but we can do our best to ensure he is not rushed and is given time to decide. He may require additional information and he may also need to ask further questions. It is important to be aware of pressure from other people other than yourself.

36

What difference would it make if he was very ill and not fully understanding? How would you manage this?

If the patient was very unwell or you were unsure of his understanding of what was going on you would first need to check his neurological/cognitive level at this point in time. You need to see if he understands what is going on (see Keenin, for how to check understanding), a simple way of doing this in an acute setting would be to ask the patient to explain to you what process is going to occur now. This should be done with all patients regardless to ensure they understand what is happening and risks that may be involved.

Legally this is called having capacity - the ability to make your own decisions. The law says you have incapacity for making medical decisions if you

Cannot understand:

  • why you need medical treatment
  • what the medical treatment is
  • how the treatment is given
  • the risks and benefits of having medical treatment OR
  • you cannot communicate that you will or will not have the treatment

 

If any of the above are present in the individual then the following should occur:

  • Identify if he has nominated a medical enduring power of attorney to make medical decisions for him
  • Identify if the individual has written up an advance care plan- a document that lays out your wishes should you not be able to make them 

If there is no legal nomination of a person, immediate family members should be consulted to identify if they knew what his wishes are, legally these individuals are all ‘person responsible’ - the order of hieracy: a legally appointed guardian, a spouse or de facto partner, a person who provides or arranges personal care for you (and who is not paid to do so), a friend or relative that you have an ongoing close and personal relationship with

37

Legal obligations:  What does this particular person want to know? What would a reasonable person in this position want to know?  Have you honestly and fully answered any specific questions he has asked? How will his home situation impact upon his decision to comply with medical advice? Financial/emotional implications of illness?

  • What does this particular person want to know?
  • Information about why he is feeling the way he is (cause of chest pain).
  • Education about what may happen and the possible consequences if he does not address the health issue.
  • Investigations that are required.
  • His treatment options including benefits and risks.
  • Management and plan.

 

  • What would a reasonable person in this position want to know?
  • A level of information that allows the patient to consider all aspects of their health and make an appropriate decision based on the options presented to them.

 

  •  How you honestly and fully answered question?
  • This can be determined by checking the patient’s level of understanding and asking him if he has any further questions or if there is any other details he would like to know.

 

  • How will his home situation impact upon his decision to comply with medical advice?
  • Geographic location - distance to travel for check ups/treatment
  • Access to services/support
  • Level of assistance at home
  • Obstinate - may feel he is too busy around the home with other responsibilities to look after himself.

 

  • Financial/emotiaonl implications of illness

Financial:

  • Inability to work à loss of income
  • Healthcare costs
  • Travel costs
  • Private health care/insurance

Emotional:

  • Anxiety/depression
  • Feeling upset, annoyed, helpless, stressed, lonely
  • Concern for the future
  • Family breakdown