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Cardiovascular medicine
Ischaemic heart disease
Refers to imbalance between supply of oxygen and demands of myocardial
tissue
Causes:
Narrowing of coronary vessels
- Atherosclerosis of Coronary arteries Most common cause
- Coronary artery thrombosis
- Coronary artery spasm
- Vasculitis (Polyarteritis Nodosa)
Increased cardiac demand
- Thyrotoxicosis
- Sympathomimetic use
- Myocardial hypertrophy (Hypertension & Stenosis)
Reversible risk factors can be targeted to reduce risk of future events
Risk of cardiovascular disease in future (Myocardial infarction, Stroke or Heart
failure) are assessed using the QRISK2 score.
Greater or equal to 10% score is target for primary prevention
Statin offered those with above score
- 20mg Atorvastatin 1
st
line
- Follow up patients at 3 months and do full lipid profile
- If non HDL cholesterol has not fallen by 40% then discuss
lifestyle, medication compliance and consider upping dose to
80mg
In secondary prevention i.e. Event has already happened:
- 80mg Atorvastatin 1
st
line
Irreversible risk factors for Atherosclerosis
Age
Gender More common in men & post-menopausal women
Family history Especially if first degree relatives with IHD before age of 50
Race
Reversible risk factors Atherosclerosis
Hyperlipidaemia
Cigarette smoking
Hypertension
Metabolic causes (Obesity, Diabetes)
Diet Especially those high in fats
Lack of exercise, stressful life etc..
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Complications of IHD are:
Stable Angina Chronic Ischaemia
Acute coronary syndrome Acute ischaemia
Stable angina
Most common cause is IHD secondary to atherosclerosis
Pathophysiology of atheroma formation:
Due to underlying risk factors the intima is damaged
Damaged tissue more permeable to LDLs
Macrophages engulf and oxidize LDLs (Foam cell),
eventually die forming fatty streak
Progress to chronic inflammation resulting in fibrous cap
formation around fatty streak
Angina is defined as a chest pain arising from heart as a resulting from
myocardial ischaemia, can be:
Classical/Stable Central chest pain which is brought on by exercise and
relieved by rest. Can be exacerbated by anger, cold weather and
excitement. Radiates to the arm and neck.
Decubitus Angina On lying down
Nocturnal Angina At night
Prinzmetal Angina Angina that occurs without provocation at rest, due
to vasospasm. Multiple that occur.
Cardiac syndrome X Symptoms of angina, positive exercise test but
normal angiography
Unstable angina Rapid increase in severity and occurring at rest,
considered under ACS.
Investigations
Clinical history & examination
Blood pressure
Bloods:
Fasting glucose/Random glucose
Lipid profile
ECG
Normal between attacks
During attacks
- ST Segment depression & T wave inversion
Exercise stress test
Positive in most but negative test should not exclude diagnosis
ST segment depression /Fall in BP at a low workload suggests severe IHD
Indication for coronary angiography
Pharmacological stress test/Myocardial perfusion/Stress echo
Used if Exercise stress test cannot be done e.g. Baseline ECG
abnormalities
Coronary angiography
Used to determine anatomy before intervention
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