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Ischaemic Heart Disease

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Ischaemic Heart Disease Khalid Husain Sachak Warwick Cardiology Society Q. How would you manage a patient with stable angina? (4) Lifestyle modification Stop smoking ... – PowerPoint PPT presentation

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Title: Ischaemic Heart Disease


1
Ischaemic Heart Disease
  • Khalid Husain Sachak
  • Warwick Cardiology Society

2
  • These ESA style questions are made by myself,
    they are not necessarily representative of the
    style/content of examinations used by WMS but I
    hope you find them useful.
  • Good luck with exams.

3
Q. Define ischaemic heart disease (1)
4
  • IHD is characterized by
  • reduced blood supply
  • i.e ischaemia of the heart muscle
  • The majority of which is caused by
  • coronary artery atherosclerosis

5
Q. Atherosclerosis is the main cause of IHD. Name
4 other causes of IHD (4)
6
  • Emobolism
  • Coronary spasm
  • Congenital arterial disease
  • Arteritis

7
IHD presents as
  1. Stable angina
  2. Acute coronary syndrome

8
Q. Describe what is meant by stable angina (2)
9
  • Stable Angina
  • Ischaemic chest pain occuring when myocardial
    oxygen demand exceeds oxygen supply
  • Must be bought on by exertion and relieved at
    rest

10
Q. What are the 3 components of Acute Coronary
Syndrome (1.5)
11
  • Acute coronary syndrome
  • Unstable angina
  • Myocardial infarction
  • NSTEMI
  • STEMI

12
Q1. Define unstable angina (1)
13
  • Unstable angina is defined as recurrent episodes
    of angina on minimal effort or at rest.
  • It may be the initial presentation of ischaemic
    heart disease, or it may represent the abrupt
    deterioration of a previously stable anginal
    syndrome

14
Q2. Define STEMI AND NSTEMI (2)
15
  • STEMI
  • (ST Elevation Myocardial Infarction)
  • One sole criteria
  • ST elevation on ECG

16
  • NON STEMI
  • (Non ST Elevation Myocardial Infarction)
  • Atleast two of the following criteria
  • Symptoms at rest
  • Raised serum Troponin
  • ECG changes

17
Q3. Pathologically, what does a STEMI indicate?
(1)
18
  • That the infarction is transmural

19
Atherosclerosis- The cause of ischaemia
20
Q. Describe the key steps in atheroma formation
(5)
21
  • LDL cholesterol crosses damaged epithelium and is
    oxidised
  • Monocytes enter, differentiating into macrophages
  • Oxidised LDL is taken up by macrophages
  • Lipid laden macrophages form fatty streak
  • Endothelium is exposed to LDLs causing
  • Angiotensin II release
  • Stimulates vasoconstriction, platelet
    aggregation, and vascular smooth muscle cell
    proliferation

22
  • Macrophages
  • They express cytokines, triggering the
    inflammatory response
  • Lymphocytes enter

23
  • MMPs and ECM secreted by smooth muscle cells
  • Formation of the fibrous cap

24
Q. State 3 mechanisms by which the atheroma can
lead to ischaemia
25
  • Plaque rupture and overlying thrombosis
  • Emboli
  • Progressive stenosis

26
Q. Risk Factors for IHD? (4)
27
  • Fixed
  • Age
  • Male sex
  • Menopause
  • Family history
  • Diabetes
  • Modifiable
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Obesity
  • Alcohol
  • Sedentary lifestyle

28
HistoryChest pain (gripping,
crushing)Radiation to neck, jaw,
epigastriumAssociations Breathlessness, NV
29
List some findings on examination of a patient
with ACS?
30
  • Pallor
  • Restless
  • Sweating
  • Pyrexial
  • Arrythmia
  • New murmur from septal rupture
  • Signs of shock
  • Hypotension
  • Tachycardia
  • Cold peripheries

31
Q. Investigations in a patient presenting with
symptoms of IHD? (3)
32
  • ECG
  • Initially hyperacute T waves, then ST elevation,
    then T wave inversion then Q waves
  • Bloods
  • FBC, UEs, LFTs, Glucose, Cardiac enzymes e.g. CK
    MB and Troponins.
  • ? Echo Chest x-ray?

33
END
34
Q. How would you manage a patient with stable
angina? (4)
35
  • Lifestyle modification
  • Stop smoking
  • Good diabetic control
  • Cut down alcohol
  • Lose weight reduces myocardial work
  • Symptom control
  • Nitrates dilate coronary arteries
  • Rest

36
Stable angina Management
  • Drug therapy
  • Antihypertensives
  • Statins help prevent plaque rupture, ? LDL
  • Aspirin antiplatelet
  • Beta blockers
  • Antagonists of adrenaline noradrenaline
  • Reduced contractility and heart rate
  • Calcium antagonist
  • Vasodilation (especially dihydropyidines)
  • Prolongation of action potential, antidysrrythmic

37
Stable angina Management
  • Coronary revascularisation
  • PCI (angioplasty/stenting)
  • Angina post myocardial infarction
  • Unstable angina
  • Severe IHD
  • Stable angina uncontrolled by medication

38
Q. Management of a patient with unstable
angina/NSTEMI?
39
  • Admit to CCU
  • Oxygen, IV access, monitor vital signs
  • Analgesia (e.g. morphine)
  • Aspirin and clopidogrel (loading)
  • Beta blocker
  • Look for improvement
  • If no improvement angiography and consider
    revascularisation.

40
Immediate Management
  • Airway
  • Breathing oxygen, RR, sats, creps
  • Circulation BP, HR, cannula, bloods, monitoring
    if unstable, CRT
  • Disability GCS, BM
  • Exposure Other causes for chest pain, abdomen,
    calves

41
Immediate Management
  • MONA
  • Morphine analgesia and reduced preload
  • Metoclopramide (avoid cyclizine)
  • Oxygen
  • Nitrates vasodilator
  • Aspirin 300mg, Clopidogrel 300mg

42
Reperfusion Therapy
  • Percutaneous Coronary Intervention
  • Used for STEMI as these suggest full thickness
    infarction
  • Should be done in lt90mins
  • Method Occluded vessel identified, guidewire
    passed, balloon inserted, stent inserted
  • Advantages
  • Culprit artery re-opened to normal calibre
  • Lower risk of major bleeding

43
Reperfusion Therapy
  • Thrombolysis
  • Advantages easy to perform, can be done quickly
  • Disadvantages
  • Inability to achieve reperfusion in all cases
  • Risk of inducing bleeding
  • Cannot detect success of reperfusion
  • Contraindications
  • Recent CVA or previous haemorrhagic stroke
  • Recent surgery
  • Active bleeding

44
Secondary prevention
  • Low Molecular Weight Heparin 1mg/kg OD
  • Aspirin
  • Clopidogrel
  • Beta blocker usually Bisoprolol
  • ACE inhibitor usually Ramipril
  • Glycoprotein IIb/IIIa inhibitor
  • Statin
  • Omacor
  • Cardiac rehabilitation

45
CABG
  • Usually reserved for severe triple vessel disease
    not amenable to PCI
  • Two forms
  • Vein grafts leg saphenous veins, quick to
    apply, annual failure 8
  • Arterial grafts more technically difficult,
    better long term survival, uses internal mammary
    artery
  • 1 mortality if elective
  • Prior to surgery optimise diabetes, do
    pulmonary function tests and vein mapping

46
Early Complications of MI (24-72 hrs)
  • Cardiogenic shock
  • Arrythmia
  • Heart block
  • Pericarditis
  • Myocardial rupture
  • Thromboembolism

47
Late complications of MI (72 hours)
  • Ventricular rupture
  • Septal rupture
  • Ventricular aneurysm
  • Tamponade
  • Dresslers Syndrome (pericarditis 2-10 weeks post
    MI)

48
Post MI counselling
  • Explain medications and their use
  • 2 months off work and avoid heavy labour
  • Avoid sex for one month
  • Build up exercise gently
  • Stop smoking
  • Reduce alcohol
  • Avoid driving for 4-6 weeks
  • Avoid flying for 2 months

49
Cardiac sounding chest pain
ECG ST elevation
Normal ECG
ECG non specific changes (T wave inversion, ST
depression, Q waves, AF)
STEMI
12 hour troponin I
Positive Trop I
Negative Trop I
Reperfusion
NSTEMI
Unstable angina
PCI
Thrombolysis
Medical Management
Medical management
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