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05/10/2023 Ischemic Heart Disease 1 Ischaemia Infarction (increased troponin) Healthy/asymptomatic Stable Angina Unstable Angina NSTEMI STEMI • CP on exertion • CP at rest Raised troponin with • ST elevation on • Troponin normal • S+S of ACS either: ECG or • ECG normal • Normal troponin with • Normal ECG or • LBBB either: • Other ECG (also consider other • Normal ECG or changes (ST ddx) • Other ECG depression, T • PCI(in 2hrs) changes (ST wave inversion) • Thrombolysis • GTN spray depression, T (after 2 hrs) Either/both: wave inversion) • B-blocker • Ticagrelor • CCI • Anticoagulant: Fondaparinux Surgical: PCI/CABG GRACE score >3: consider PCI Occlusion of coronary artery 2 05/10/2023 Pathophysiology 3 Normal: coronary arteries supply the heart with Oxygen In pts with Ischaemic Heart Disease: you get a decreasedsupply of oxygen to the heart Most important cause to remember: Atherosclerosis (fatty plaques in vessel walls) Acute Coronary Syndrome: Result of a thrombus from an atherosclerotic plaque blocking a coronary artery 4 05/10/2023 RFs for Atherosclerosis Non- PMH: Modifiable modifiable •Diabetes •Age >= 65 •Overweight •Hypertension •Family history •Diet (high of Coronary LDL, low HDL) artery disease •Smoking 5 Atherosclerosis 1. Endothelialdysfunction(stress, chemical age)tants, high Cholestrol, DM, HTN, HF, smoking, 2. Disruption of this barrier meanscirculating LDLs can enter the intima andare trapped so accumulate 3. Lipids phagocytosedby macrophagesin intima – make raised “fatty streak” 4. Some lipids releasedby macrophageswhich stimulate collage secretion 5. Collagen covers plaquesurface 6.ulcerates – complicated atheroma This surface Bifurcation areas are common depositionsites 6 05/10/2023 7 Acute Coronary syndrome NSTEMI (non-ST Stable Angina Unstable Angina elevation myocardialSTEMI (ST-elevated infarction) myocardial infarction) 70% 90% 90% 100% Occlusion of coronary artery 8 05/10/2023 9 Ischaemia Infarction Healthy/asymptomatic Stable Angina Unstable Angina NSTEMI STEMI Chest Pain on Chest Pain at rest Characteristic ECG changes exertion Occlusion of coronary artery 10 05/10/2023 Presentation 11 S+S Central Constricting “like a Chest pain tight band around you” Nausea + vomiting Spreads to jaw/arms Should continue at rest for Sweaty + clammy more than 15 minutes Shortness of Breath Palpitations 12 05/10/2023 Investigations 13 Ix bedside • Full CV examination • ECG Bloods • Baseline • FBC (anaemia) • UE (before giving meds) • LFTs (before statins) • Troponin • Lipid profile • HBA1c + fasting glucose Imaging • CXR (differentials?) • Echo (functional damage) • CT angiogram 14 05/10/2023 15 Ischaemia Infarction (increased troponin) Healthy/asymptomatic Stable Angina Unstable Angina NSTEMI STEMI • CP on exertion • CP at rest Raised troponin with • ST elevation on • Troponin normal • S+S of ACS either: ECG or • ECG normal • Normal troponin with • Normal ECG or • LBBB either: • Other ECG (also consider other • Normal ECG or changes (ST ddx) • Other ECG depression, T changes (ST depression, T wave inversion) wave inversion) Occlusion of coronary artery 16 05/10/2023 ECGs 17 18 05/10/2023 How do we know where the infarct is? Useful to know some basic coronary artery anatomy to help Right coronary artery: R L • RA • RV • Inferior aspect of LV • Posterior septal area Circumflex artery supplies: • LA • Posterior aspect of LV Left anterior descending artery: • Anterior aspect of LV • Anterior aspect of septum On an ECG, each of the leads corresponds to a different region on the heart because they are all looking at the heart at different angles. 19 20 05/10/2023 Artery Heart Area ECG Leads R L Left coronary artery Anterolateral I, aVL, V3-6 (V1+2 but not in isolation) Left anterior descending Anterior V1-4 Circumflex Lateral I, aVL, V5-6 Right coronary artery Inferior II, III, aVF How to figure it out: 1. Where on the ECG is the infarct? (look for ST elevation) 2. Which region does this correlate to? 3. Which artery/arteries supply this region? 21 22 05/10/2023 Management 23 Mx of ACS 24 05/10/2023 Mx of ACS Initial mx for all pts with ACS: M: Morphine IV (for pain if required w. antiemetic eg. metoclopramide) O: Oxygen (only if required – check Obs) N:Nitrate (GTN) A: Aspirin 300 mg 25 Mx of ACS Mx of STEMI Pts w STEMI presenting within 12hrs of onset discuss urgently for either: 1. Percutaneous coronary intervention (PCI) • if available within 2 hrs of presenting 2. Thrombolysis (PCI not available within 2 hours) • Break down fibrin in blood clots • Risk bleeding (can be dangerous) 26 05/10/2023 Mx of ACS Mx of NSTEMI • Ticagrelor 180mg stat • Clopidogrel if high bleeding risk • Prasugrel if having angiography • Anticoagulant: Fondaparinux (unless high bleed risk or immediate angiography Unstable pts considered for immediate angiography (similar to STEMI) GRACE score: 6 month probability of death after NSTEMI 3%>= 3%< Medium/high risk: consider early angiography w PCI (within 72 hrs) 27 Ongoing management Afterwards: • Echo (once stable – assess functionaldamage) • Cardiac rehab • Secondary prevention (6As) • Aspirin 75mg OD indefinitely • Another Antiplatelet (ticagrelor/clopidogrel) 12m • Atorvastatin 80mg OD • ACEI (eg. Ramipril) titrate • Atenolol (titrate) • Aldosterone antagonist (if HF) titrate to 50mg OD 28 05/10/2023 MX STABLE ANGINA Immediate symptomatic relief • GTN spray Extra IX may be useful in non- Long-term symptomatic relief acute setting: Either/both: • B-blocker • Cardiac stress testing • CCI (rate-limiting but DHP if w. b-blocker) • CT angiography (first line) (Avoid both in HF) • Invasive coronary angiography (gold standard for ddx CAD) Specialist: • Long-acting nitrates (e.g., isosorbide mononitrate) • Ivabradine • Nicorandil • Ranolazine Secondary Prevention of CVD (6As) Surgical interventions offered if severe/medical doesn’t help: • PCI • CABG 29 Ischaemia Infarction (increased troponin) Healthy/asymptomatic Stable Angina Unstable Angina NSTEMI STEMI • CP on exertion • CP at rest • Troponin normal • S+S of ACS Raised troponin with • ST elevation on • ECG normal • Normal troponin with either: ECG or either: • Normal ECG or • LBBB • Normal ECG or • Other ECG (also consider other • Other ECG changes (ST ddx) changes (ST depression, T • PCI(in 2hrs) depression, T wave inversion) • Thrombolysis • GTN spray wave inversion) (after 2 hrs) Either/both: • B-blocker • Ticagrelor • CCI • Anticoagulant: Fondaparinux Surgical: PCI/CABG GRACE score >3: consider PCI Occlusion of coronary artery 30 05/10/2023 Please fill in this feedback form for this half of the session  31 Test your knowledge! Amna Alanni 32 05/10/2023 A 67-year-old male patient presents with a 2-hour history of central crushing chest pain radiating to the jaw. The chest pain is present at rest. Upon examination the patient appears clammy. What are the two most important initial investigations to order? a. ECG and echocardiogram b. ECG and troponin c. ECG and lipid levels d. Echocardiogram and troponin e. Echocardiogram and lipid levels 33 A 67-year-old male patient presents with a 2-hour history of central crushing chest pain radiating to the jaw. The chest pain is present at rest. Upon examination the patient appears clammy. What are the two most important initial investigations to order? a. ECG and echocardiogram b. ECG and troponin c. ECG and lipid levels d. Echocardiogram and troponin e. Echocardiogram and lipid levels 34 05/10/2023 A 67-year-old male patient presents with a 2-hour history of central crushing chest pain radiating to the jaw. The chest pain is present at rest. Upon examination the patient appears clammy. An ECG is performed which comes back normal. Troponins come back raised. What is the most likely diagnosis? a. Stable angina b. Unstable angina c. NSTEMI d. STEMI e. Myocarditis 35 A 67-year-old male patient presents with a 2-hour history of central crushing chest pain radiating to the jaw. The chest pain is present at rest. Upon examination the patient appears clammy. An ECG is performed which comes back normal. Troponins come back raised. What is the most likely diagnosis? a. Stable angina b. Unstable angina c. NSTEMI d. STEMI e. Myocarditis 36 05/10/2023 37 A 67-year-old patient presents with a 2-hour history of central crushing chest pain radiatingto the jaw. The ECG is shown below. Which vessel is most likely occluded? a. Right coronary artery b. Left circumflex artery c. Left anterior descending artery d. Right marginal e. Aorta 38 05/10/2023 A 67-year-old patient presents with a 2-hour history of central crushing chest pain radiating to the jaw. The ECG is shown below. Which vessel is most likely occluded? a. Right coronary artery b. Left circumflex artery c. Left anterior descending artery d. Right marginal e. Aorta 39 ECG leads Region of heart Vessel V1, V2, V3, V4 Anterior Left Anterior Descending (note V1, V2 = septal) II, III, aVF Inferior Right Coronary Artery I, aVL, V5, V6 Lateral Left Circumflex V1, V2, V3, V4 Anterolateral Left Main Artery AND I, aVL, V5, V6 (note: some sources state LAD or Left circumflex- therefore this question is unlikely) 40 05/10/2023 A 44-year-old patient presents with central crushing chest pain at rest. The pain is severe, has been present for 30 minutes and has not subsided with rest. The patient has significant risk factors for coronary artery disease and an MI is suspected. Their observations are as follows: HR 89 BPM, sats 97%, RR 19, BP 149/98, temp 37. Whilst the nurse fetches the ECG machine to confirm the diagnosis, what is the best initial management plan? a. Codeine PO, oxygen, GTN spray b. Morphine IV, oxygen, GTN spray, aspirin 300mg c. Codeine PO, aspirin 300mg, IV nitrates d. Morphine IV, GTN spray, aspirin 300mg e. Codeine PO, aspirin 75mg, GTN spray 41 A 44-year-old patient presents with central crushing chest pain at rest. The pain is severe, has been present for 30 minutes and has not subsided with rest. The patient has significant risk factors for coronary artery disease and an MI is suspected. Their observations are as follows: HR 89 BPM, sats 97%, RR 19, BP 149/98, temp 37. Whilst the nurse fetches the ECG machine to confirm the diagnosis, what is the best initial management plan? a. Codeine PO, oxygen, GTN spray b. Morphine IV, oxygen, GTN spray, aspirin 300mg c. Codeine PO, aspirin 300mg, IV nitrates d. Morphine IV, GTN spray, aspirin 300mg e. Codeine PO, aspirin 75mg, GTN spray 42 05/10/2023 Initial management of acute ACS • M – morphineand antiemetic • O- oxygen ONLY if sats <94%  in those without type 2 resp failure then simple facemask, 5-10 L to maintain to 94-98%, if risk of type 2 failure use venturi mask and titrate sats to 88%-92% • N- nitrates (GTN) (note: contraindicated if systolicBP <90mmHg) • A – aspirin 300mg loading dose 43 A 70-year-old male presents to A+E with a “tight feeling” in his chest. The pain is 6/10, radiates to the left arm and is present at rest. The pain started an hour and a half ago and the patient is stable. ECG reveals ST elevation in inferior leads. The nearest centre for angiographyand PCI is 10 minutesaway. The first responders have already initiated GTN, aspirin 300mgand morphine. The patient asks you what happens next. What is the best next step in his management plan? a. Arrange an immediate transfer to the nearest centre for PCI b. Initiate work up for thrombolysis c. Perform a GRACE score d. Start ramipril, bisoprolol, aspirin 75mg, clopidogrel 75mg and atorvastatin 80mg e. Continue current management and arrange PCI within 72 hours 44 05/10/2023 A 70-year-old male presents to A+E with a “tight feeling” in his chest. The pain is 6/10, radiates to the left arm and is present at rest. The pain started an hour and a half ago and the patient is stable. ECG reveals ST elevation in inferior leads. The nearest centre for angiographyand PCI is 10 minutesaway. The first responders have already initiated GTN, aspirin 300mgand morphine. The patient asks you what happens next. What is the best next step in his management plan? a. Arrange an immediate transfer to the nearest centre for PCI b. Initiate work up for thrombolysis c. Perform a GRACE score d. Start ramipril, bisoprolol, aspirin 75mg, clopidogrel 75mg and atorvastatin 80mg e. Continue current management and arrange PCI within 72 hours 45 STEMI management ANGIOGRAPHY + PCI = if presenting within 120 minutes (and <12 hours since onset) STEP 1:  offer if presenting within 12 hours of symptoms and if PCI can be management ASAP (mainly delivered in 120 mins. for symptom relief)  drug therapy for PCI: MONA - not taking oral anticoagulants: aspirin + prasugrel - taking oral anticoagulant: aspirin + clopidogrel STEP 2: Manage/ treat the MI OR if >2 hours STEP 3: Prescribe secondary prevention medications before discharge THROMBOLYSIS if presenting in 12 hours and PCI cannot be given in 120 mins Examplesof drugs used: alteplase, streptokinase. RISK: significant risk of bleeding. 46 05/10/2023 Contraindications to thrombolysis Contraindications to thrombolysis  active internal bleeding  recent haemorrhage, trauma or surgery (including dental extraction)  coagulation and bleeding disorders  intracranial neoplasm  stroke < 3 months  aortic dissection  recent head injury  severe hypertension Side-effects  haemorrhage  hypotension - more common with streptokinase  allergic reactions may occur with streptokinase 47 A patient with multiple CVD risk factors, presents with acute onset chest pain. ECG confirms ST depression in anterior leads and troponin is raised. What is the scoring system which should be calculated for this patient’spresentationin order to determine 6-monthmorality and to aid management decisions? a. QRISK b. HeartScore c. CHADVASC d. GRACE e. Framingham Risk Score 48 05/10/2023 A patient with multiple CVD risk factors, presents with acute onset chest pain. ECG confirms ST depression in anterior leads and troponin is raised. What is the scoring system which should be calculated for this patient’spresentationin order to determine 6-monthmorality and to aid management decisions? a. QRISK b. HeartScore c. CHADVASC d. GRACE e. Framingham Risk Score 49 A patient with multiple CVD risk factor, presents with acute onset chest pain starting20 minutes ago. ECG confirms ST depression in anterior leads and troponin is raised. A grace score is calculated to be 2. The patient has already received the hyperacute management of MI, includingmorphine and aspirin 300mg. It is now decided the patient should be admitted. What is the best management plan going forwards? a. Arrange PCI within 120 minutes b. Start fondaparinux, dual antiplatelet therapy and arrange PCI within 72 hours c. Start fondaparinuxand dual antiplatelet therapyonly d. Calculate QRISK and if low discharge with secondary prevention medications only e. Thrombolysis 50 05/10/2023 A patient with multiple CVD risk factor, presents with acute onset chest pain starting 20 minutes ago. ECG confirms ST depression in anterior leads and troponin is raised. A grace score is calculated to be 2. The patient has already received the hyperacute management of MI, includingmorphine and aspirin 300mg. It is now decided the patient should be admitted. What is the best management plan going forwards? a. Arrange PCI within 120 minutes b. Start fondaparinux, dual antiplatelet therapy and arrange PCI within 72 hours c. Start fondaparinux and dual antiplatelet therapy only d. Calculate QRISK and if low discharge with secondary prevention medications only e. Thrombolysis 51 NSTEMI management Start fondaparinux (whilst in hospital) + DAPT Perform a GRACE score. If GRACE score is >3  PCI in 72 hours 52 05/10/2023 You are an F1 on the cardiology ward. You have been asked to prescribe secondary prevention medications to a patient who has recently had ACS in the form of unstable angina. What should you prescribe? a. Ramipril, Atorvastatin 80mg, Aspirin 75mg b. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg c. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg indefinitely and ticagrelor for 12 months d. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg and ticagrelor indefinitely e. Ramipril, Atorvastatin80mg, ticagrelor 53 You are an F1 on the cardiology ward. You have been asked to prescribe secondary prevention medications to a patient who has recently had ACS in the form of unstable angina. What should you prescribe? a. Ramipril, Atorvastatin 80mg, Aspirin 75mg b. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg c. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg indefinitely and ticagrelor for 12 months d. Ramipril, Bisoprolol, Atorvastatin 80mg, Aspirin 75mg and ticagrelor indefinitely e. Ramipril, Atorvastatin80mg, ticagrelor 54 05/10/2023 Secondary Prevention following ACS • ACE INHIBTIOR • BETA BLOCKER • ASPIRIN (INDEFINATELY) + 2D ANTIPLATLET (FOR 12 MONTHS) • STATIN – atorvastatin 80mg Remember ACS includes unstable angina, NSTEMI and STEMI 55 A 74-year-old female presents to her GP presenting with recurrent episodes of a tight crushing feeling in her chest. The pain often comes on during her morning walking club but subsides within a few minutesafter she sits down. Her observationsand ECG are normal. She has no relevant past medical history. What is the first line investigation to confirm the diagnosis? a. 24-hour ECG b. CTCA c. Echocardiogram d. Exercise tolerance test e. Contrast enhanced MRI 56 05/10/2023 A 74-year-old female presents to her GP presenting with recurrent episodes of a tight crushing feeling in her chest. The pain often comes on during her morning walking club but subsides within a few minutesafter she sits down. Her observationsand ECG are normal. She has no relevant past medical history. What is the first line investigation to confirm the diagnosis? a. 24-hour ECG b. CTCA c. Echocardiogram d. Exercise tolerance test e. Contrast enhanced MRI 57 Stable angina First line investigation: = CT CORONARY ANGIOGRAM(CTCA) - Generally significant coronary artery disease is 50% in the left main coronary artery.vessel or ≥ • CTCA is considered a non-invasive Second line investigations: ANATOMICAL test and can see the whole vessel- not just the lumen. if CT coronary angiography is unclear then do a non- invasive It requires a cannula for the dye. FUNCTIONAL test e.g.  myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or  stress echocardiography or  first-pass contrast-enhanced magnetic resonance (MR) perfusion or  MR imaging for stress-induced wall motion abnormalities. 58 05/10/2023 Good luck everyone! Feedback  59