Investigations

• What is shown in the image?

  Anterior STEMI

  
• What is shown in the image?

  Inferior STEMI

  
• What are the different classifications of stable angina?

  Class I

  Class II

  Class III

  Class IV
• What is class I stable angina?

  No angina with ordinary activity

  Angina with strenuous activity
• What is class II stable angina?

  Angina during ordinary activity (e.g. walking up hills, walking rapidly upstairs) with mild limitation of activities
• What is class III stable angina?

  Angina with low levels of activity (e.g. walking 50-100m on flat, walking up 1 flight of stairs) with marked restriction of activities
• What is class IV stable angina?

  Angina at rest or with any level of exercise
• Apart from stable & unstable, what are the other types of angina?

  Atypical

  Non-angina chest pain

  Variant (Prinzmetal's)

  Refractory

  Microvascular
• What is atypical angina?

  Chest pain with 2/3 features of classical angina
• What is non-angina chest pain?

  Chest pain with 1/3 features of classical angina
• What is variant (Prinzmetal's) angina?

  Caused by coronary artery spasm -> angina w/o provocation (usually at rest)

  ST elevation on ECG (during pain)
• What is refractory angina?

  Pts with severe coronary disease when revascularisation is not possible & angina is not controlled by medical therapy
• What is microvascular angina?

  Symptoms of angina, positive exercise test & normal coronary arteries on angiogram

  Thought to result from functional abnormalities of coronary microcirculation
• What is unstable angina?

  Chest pain

  Increases rapidly in severity (occurs at rest, or is recent onset (less than 24 hrs))

  Acute coronary syndrome
• What should be done on examination for angina?

  Angina usually shows no abnormal findings

  Essential to exclude aortic stenosis as the cause

  BP should be taken (for HTN)

  BMI should be measured
• What are the investigations for angina?

  FBC

  TFTs

  Fasting glucose

  HbA1c

  Fasting lipid profile

  GFR

  Troponin (if unstable)

  ECG

  Echocardiography

  CXR
• Why is an ECG done in angina?

  To exclude

  • coronary syndrome
  • pathological Q waves
  • left ventricular hypertrophy
  • left bundle branch block
• Why is echocardiography done in angina?

  To look for;

  • regional wall motion abnormalities
  • left ventricular ejection fraction
  • diastolic function
  • alternative causes of chest pain
• Why is a CXR done in angina?

  To look for;

  • pulmonary disease
  • heart failure
• What are the acute coronary syndromes?

  STEMI

  NSTEMI

  Unstable angina
• What information does an echocardiogram give?

  Used to see how chambers & valves are pumping blood through heart

  Used to evaluate wall motion abnormalities

  Gives information about size/shape/structure of heart

  Assess pumping action
• What is reduced & severely reduced ejection fraction classified as?

  Reduced EF < 40%

  Severely reduced EF < 30%
• What are the differential diagnosis of MI?

  Stable angina

  Myocarditis

  PE

  Oesophageal rupture

  Acute cholecystitis

  Pericarditis

  Anxiety
• What is the healthy range of cholesterol?

  200 mg/dL or less

  Women typically have higher levels of HDL than men
• What is the procedure of an angiography?

  Usually done under LA

  Catheter inserted into artery at wrist, arm or groin

  Catheter guided to area for examination

  Dye injected into catheter

  Series of X-rays taken as dye flows through vessels

  Images highlight any abnormalities for diagnosis
• What is angiography?

  Type of X-ray used to check blood vessels

  Must inject dye into vessels

  Used in diagnosis of atherosclerosis, brain aneurysm, PE, etc.
• What is anterior akinesia on echocardiogram?

  Lack of anterior wall motion

  Lack of anterior wall thickening

  Possibly due to cell death in the myocardium following MI

  
• What is normal ejection fraction?

  50 - 75%
• What are the cardiac markers?

  Troponin T

  Troponin I

  CK-MB (creatine kinase MB)

  Myoglobin
• What is QRISK3?

  Online calculator that uses algorithm to calculate an individuals risk of an MI in next 10 years
• What is ejection fraction?

  Percentage of how much blood is ejected from the ventricle with each contraction
• How are Troponin T & I used to diagnose MI?

  Very specific & sensitive for myocardial injury

  Released within 4-6 hours of an MI -> remain elevated for 2 weeks
• What causes raised troponin?

  MI

  Tachy/bradyarrhythmias

  Aortic dissection

  Severe aortic valve disease

  Hypertrophic cardiomyopathy

  Severe resp failure

  Severe anaemia

  Coronary spasm

  HF

  Sepsis

  Renal failure

  Stroke

  Subarachnoid haemorrhage
• STEMI vs NSTEMI

  STEMI

  • complete occlusion of coronary artery
  • increased risk of arrhythmia
  • management (gold standard) = PCI

  NSTEMI

  • partial occlusion of coronary artery
  • lower risk of death, worse long-term outcomes
  • management = beta blockers, ACE inhibitors, atorvastatin
• What is Type 1-5 MI?

  Type 1 -> spontaneous MI with ischaemia (e.g. plaque rupture)

  Type 2 -> MI secondary to ischaemia (e.g. coronary spasm)

  Type 3 -> MI in sudden cardiac death

  Type 4a -> related to PCI

  Type 4b -> related to stent thrombosis

  Type 5 -> related to CABG
• Why would you do a FBC in MI?

  Check for anaemia
• Why would you do U&Es in MI?

  Check K+, Na+, Mg+2 levels -> prevention of arrhythmia

  Baseline for investigations/management
• Why do you do a full lipid profile in MI?

  Increased risk of atherosclerosis & MI
• When should an ECG be done in MI?

  Pts with chest pain -> ECG should be done within 10 mins of 1st contact

  Should be repeated every 15 mins while pt is still in pain
• What would an ECG show in MI?

  STEMI

  • ST elevation

  NSTEMI

  • ST depression