1. Ischemic Heart Dsease (SA, UA, NSTEMI, STEMI)
2. Heart Failure
3. Cor Pulmonale
4. Mitral Valve Diseases
5. Aortic Valve Diseases
6. Hypertension
7. Atrial Fibrillation
8. Atrial Flutter
9. Heart Blocks
10. Wolff-Parkinson White Syndrome
11. Supraventricular Tachycardias
12. Ventricular Extrasystoles
13. Ventricular Tachycardia
14. Ventricular Fibrillation
15. Prolonged QT Syndrome
16. Aortic Aneurysm
17. Aortic Dissection
18. Pericarditis
19. Endocarditis
DRUGS and their Modes of Action
Ischemic Heart Disease
● Cardiac myocyte damage (and eventual death) due to insufficient oxygen-rich blood
● Can be due to increased myocardial workload + coronary artery occlusion OR due to
insufficient oxygen-rich blood supply
● (in ascending order of severity) stable angina < unstable angina < NSTEMI < STEMI
Risk Factors
● Age
● Family history
● DM
● Smoking
● obesity/lack of exercise
● Hyperlipidemia
● Outflow obstruction abnormalities (aortic stenosis/cardiomyopathy)
Symptoms of SA
● Chest pain precipitated by exertion/exposure to cold
● lasts 1-5min
● Relieved by rest/sublingual GTN spray
Symptoms for UA/NSTEMI/STEMI
● Chest pain: discomfort, heaviness, squeezing, burning
○ Prolonged, > 20 min at rest
, ○ Radiate to epigastrium, arms, shoulders, nec and jaw (mainly left arm and
neck)
● Sweating
● nausea/vomiting
● Dyspnoea
● Fatigue
Patients with DM/elderly patients may not present with chest pain!
Signs
● Vary greatly
● Low-grade fever
● Pale and cool
● Clammy skin
● hypertension/hypotension
Diagnosis
● Physical Examination
○ 3rd/4th Heart sound (caused by stiff, compliant ventricles)
○ Systolic murmur/pericardial rub (if mitral regurgitation/septal defect is primary
cause)
○ Pulmonary crackles (pulmonary oedema)
○ Elevated JVP
○ For stable angina, exclude symptoms of aortic stenosis: slow-rising carotid
pule, ejection murmur radiating to neck
● ECG
○ UA/NSTEMI
■ Could be normal or show symptoms
■ Transient T-wave inversions
■ ST-segment depression
○ STEMI
■ ST-segment elevation
■ Initially peaked T-waves, then T-wave inversion
● Cardiac Enzymes
○ SA, UA: little to no change in troponin
○ NSTEMI, STEMI: troponin, CK, myoglobin all rise and remain elevated
● FBC
○ Exclude anaemia
○ CRP: sign of inflammation
○ Hyperglycemia (reduces patient’s chance of surviving)
○ Monitor K+ levels (arrhythmias)
● CXR
○ Assess patient’s heart size, presence or absence of HF, pulmonary oedema
● Echo
○ Effect of ischemia on heart
● Coronary Angiography**
Treatment for SA
● Lifestyle: stop smoking, lose weight, control hypertension and DM
, ● Medical
○ (in the absence of contraindications) patients should receive statins (reduce
cholesterol) and aspirin (antiplatelets)
○ Nitrates: vasodilators that can abort attacks (sublingual GTN spray)
○ 1st Line: CCB/B-blockers
■ If CCB is used as first line, use rate-limiting (non-dihydropyridine) one
like verapamil
■ If CCB is used with B-blocker, use long-acting one like amlodipine
■ DO NOT combine a beta-blocker with a rate-limiting (non-
dihydropyridine) CCB as severe bradycardia and heart failure can
occur
● Surgery
○ Coronary artery bypass graft (CABG) - section of blood vessel is taken from
another part of the body and used to reroute blood flow past a blocked/narrow
section of artery
○ Percutaneous coronary intervention (PCI), AKA coronary angioplasty - where
a narrowed section of artery is widened using a tiny tube called a stent
○ CABG is usually the preferred surgical option for people who:
■ have diabetes, and/or
■ are over 65 years of age, and/or
■ have blockages in 3 or more blood vessels that supply the heart with
blood
**CCBs like verapamil should be avoided in patients with heart failure
Treatment for UA/NSTEMI: BMOAN (Morphine, Oxygen, Aspirin, Nitrate + B-
blockers)
, Treatment for STEMI: same as for UA/NSTEMI but without time to do angiography
Subsequent management for all patients
● Dual antiplatelet therapy (aspirin +2nd antiplatelet)
● ACE-inhibitor
● β-blocker: bisoprolol. If contraindicated, consider verapamil or diltiazem Statin: e.g.
simvastatin.
Heart Failure
● pathophysiologic state in which the heart fails to pump blood at a rate commensurate
with the requirements of the metabolizing tissues
● progressive ↓ in the heart’s ability to contract and relax
● Ejection fraction >40% is ejection fraction preserved HF (diastolic HF)
Risk Factors
● Ischemic heart disease, MI, cardiopathy, DM
