CVS

IHD
Scenario

Mr. Lee, a 56-year-old man, was having some chest pains lately, which
promptly resolve with rest.
He came to your clinic.
What would you ask him?
History

• SOCRATES
• Systems review: CVS and Respiratory
• Past medical history
• Family history
• Medication history
• Alcohol and smoking history
• Social history
CVS Examination

Look for:
• Abnormal lipid metabolism (xanthelasma, xanthoma)
• Diffuse atherosclerosis (absence or diminished peripheral pulses,
carotid bruit)
• Third and/or fourth heart sounds (during attack)
Diagnosis

Angina pectoris
1. Heavy discomfort to chest, jaw, neck, shoulder, arm
2. Brought on by exertion
3. Relieved within 5 minutes of rest or GTN

Typical angina = all 3 features

Atypical angina = 2 features
Non-anginal chest pain = 0-1 feature
Investigations

Diagnostic
1. CT coronary angiography
2. Non-invasive functional testing
3. Invasive coronary angiography

Other
• FBC
• TFT
• BGL/HbA1c
Management

Medical
• Relief: GTN spray or sublingual tabs
• Anti-angina:
• First line: Beta blocker (atenolol/bisoprolol) +/- CCB (amlodipine/diltiazem)
• Second line: Long-acting nitrate / ivabradine / nicorandil / ranolazine

If medications fail, consider PCI or CABG

PCI vs CABG
Management

Secondary prevention
• Aspirin 75 mg daily
• ACE inhibitors
• Statins
Scenario (cont.)

Mr. Lee was jogging in the park when suddenly he felt that “an elephant
was sitting on his chest”.
He stopped to take some rest. However, the pain got worse and started
radiating to his jaw. He quickly took his GTN medication.
10 minutes later, he was still having the pain and was gasping desperately
for air.
He called the ambulance and was rushed to the ED.
What would you do?
Managing ACS

Initial assessment:
1. Is it a cardiac cause? MONA:
• history of chest pain
• presence of cardiovascular risk factors • Morphine
•
•
history of ischaemic heart disease and any previous treatment
previous investigations for chest pain
• Oxygen (if SpO2<94%)
• Nitrates
2. Resting 12-lead ECG
(sublingual/buccal)
3. Obtain blood for cardiac markers • Aspirin 300mg
Unstable angina | NSTEMI

1. Initial drug treatment

• Continue aspirin
• Antithrombin
• Fondaparinux / Unfractionated heparin

2. Assess risk
• Low risk: Aspirin + clopidogrel
• High risk: Aspirin + clopidogrel + glycoprotein inhibitors (eptifibatide / tirofiban) +
Revascularisation
STEMI

1. Coronary reperfusion therapy (<12 hours)

• PCI (door-to-balloon time <90 min)
• Dual antiplatelet (aspirin + ADP-receptor blocker)
• Heparin / bivalirudin
• Fibrinolysis (door-to-needle time <30 min)

2. Continue dual antiplatelet

3. Treat underlying conditions
• Hyperlipidemia
• DM
• HTN
• Lifestyle modification
Complications of MI

• Immediate • Arrythmias (VT, VF)

• Early • Acute pulmonary oedema
• Cardiogenic shock
• Late

• Rupture (4-7 days)

• Pericarditis
• Dressler syndrome (2 weeks) • Mural thrombosis
• CCF
• Mural thrombosis  Emboli
ECG 1
ECG 2
ECG 3
ECG 4
ECG 5
ECG 6
ECG 7
Summary