CHAPTER 2: CVS: Myocardial Ischaemia

Question 1

What is stable angina precipitated by?

Answer 1

Exertion

Question 2

What is stable angina relieved by?

Answer 2

Rest

Question 3

What should acute attacks of stable angina be managed with?

Answer 3

Sublingual glyceryl trinitrate

Question 4

When should SL GTN be taken in stable angina?

Answer 4

Immediately before performing activities known to bring on attacks

Question 5

How many times a week should attacks occur before necessitating regular drug therapy?

Answer 5

More than twice

Question 6

What are the two options for first line management of stable angina?

Answer 6

1. Beta blocker

2. Calcium channel blocker

Question 7

What is the second step of treatment of stable angina?

Answer 7

Beta blocker + Dihydropyridine calcium channel blocker

Question 8

If there is a contra-indication to either the beta blocker or calcium channel blocker, which options can be considered? (4)

Answer 8

1. Long-acting nitrate
2. Ivabradine
3. Nicorandil
4. Ranolazine

Question 9

How often should response to treatment be assessed after initiation of drug treatment in stable angina?

Answer 9

Every 2-4 weeks

Question 10

How should drugs be introduced in stable angina?

Answer 10

Titrated to maximum tolerated dose

Question 11

What is the mechanism of action of the antianginal drugs; calcium channel blockers, nitrates, and nicorandil?

Answer 11

Vasodilation and subsequent reduction in blood pressure

Question 12

What is the mechanism of action of ivabradine?

Answer 12

Lowers heart rate by action on sinus node

Question 13

What must be monitored in patients taking ivabradine? (2)

Answer 13

1. AF

2. Bradycardia

Question 14

What is a notable side effect of nicorandil?

Answer 14

Nicorandil-induced ulceration which may progress to perforation, fistula, haemorrhage or abscess

Question 15

Which conditions does ACS encompass? (3)

Answer 15

1. Unstable angina
2. STEMI
3. NSTEMI

Question 16

Patients with ACS may present similarly, what is used to make definitive diagnosis? (3)

Answer 16

1. Clinical presentation
2. Biochemical cardiac markers
3. ECG changes

Question 17

Why do unstable angina and NSTEMI usually occur?

Answer 17

As a result of atherosclerotic plaque rupture

Question 18

How are unstable angina and NSTEMI characterised? (3)

Answer 18

1. Stable angina that suddenly worsens
2. Recurring or prolonged angina at rest
3. New onset of severe angina

Question 19

What is the difference between unstable angina and NSTEMI?

Answer 19

Myocardial necrosis present in NSTEMI

Question 20

Which drugs should be given to treat NSTEMI or unstable angina as an emergency? (5)

Answer 20

1. Oxygen
2. Nitrates (+ Morphine & Anti-emetic if in a lot of pain)
3. LMWH or Fondaparinux
4. Aspirin and Clopidogrel
5. Beta blocker (for life)

Question 21

What is the difference between STEMI and NSTEMI?

Answer 21

More irreversible necrosis of myocardium in STEMI with long term effects

Question 22

When giving oxygen for unstable angina, STEMI or NSTEMI, what must be considered as a caution?

Answer 22

Hyperoxia in COPD

Question 23

If aspirin is given before the patient arrives in hospital, what must be done?

Answer 23

A note should state that this has happened

Question 24

What are the common side effects of nitrates? (4)

Answer 24

1. Dizziness
2. Postural hypotension
3. Tachycardia
4. Throbbing headache

Question 25

What do many patients on long-acting or transdermal nitrates develop?

Answer 25

Tolerance

Question 26

How long should nitrates be left off if tolerance is suspected?

Answer 26

6-12 hours in each 24 hours, usually over night

Question 27

When should the second of two daily MR nitrate doses be given?

Answer 27

After 8hours rather than 12 hours