Australian Doctor 14th July Issue 14JULY2023 issue | Page 25

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lesion is identified in the left anterior descending coronary artery ( see figure 10 ) that is successfully opened with a drug-eluting stent .

A formal echocardiogram is conducted the following day and shows severe hypokinesis in the mid anteroseptal and apical myocardial wall with an LV systolic function of 35-40 %.

In addition to his regular perindopril , Gerald is started on atorvastatin and bisoprolol ( because of the LV dysfunction ) as well as dual antiplatelet therapy with aspirin and ticagrelor .

His HbA1c 24 hours post-admission is significantly elevated at 9.4 % ( normal 3.5-6.0 %, indeterminate 6.1-6.4 %, diagnostic of diabetes 6.5 % or greater ). Following endocrinology review , Gerald is started on basal bolus insulin and an SGLT2i , and these are continued on discharge with planned review in the hospital ' s diabetes clinic .

He is discharged home but re-presents to hospital within twenty-four hours with new chest pain ( sharp , pleuritic in nature , worsens with lying flat ) and associated fevers . A bedside echocardiogram reveals a small pericardial effusion . He is diagnosed with pericarditis in the setting of recent infarction and discharged home on regular colchicine . He has no further chest pain .

One week later , Gerald presents to his GP with a history of worsening shortness of breath both with exertion and at rest . He is unable to walk to the ensuite bathroom and describes both orthopnea and paroxysmal nocturnal dyspnoea .

The GP refers Gerald to hospital , starts him on regular low-dose frusemide for the presumptive diagnosis of left-sided heart failure and arranges for a chest X-ray . On admission , Gerald ' s diuresis is increased , and fluid restriction and salt restriction started . After a short stay , Gerald is discharged home with minimal symptoms .

1 . Which THREE conditions are part of the definition of ACS ? a Coronary artery spasm . b STEMI . c NSTEMI . d Unstable angina .

2 . Which ONE is not a risk factor for the development of atherosclerosis ? a Hypertension . b Age . c Osteoarthritis . d Obesity .

3 . Which TWO statements regarding the pathophysiology of ACS are correct ? a Atherosclerosis can develop over months . b Outward expansion of atherosclerotic arteries accommodates for the growth of plaque . c The accumulation of HDL particles within the intima of the arterial wall has been identified as a major antigenic factor in the propagation of an adaptive immune response .

His cardiologist and GP collaborate to optimise his secondary preventative care and management of ongoing symptoms from recurrent pericarditis . At his latest review he is euvolemic . The long-term plan is to transition from perindopril to sacubitril / valsartan and to consider the addition of spironolactone .

Case study two

Stefan , 90 , presents to hospital from a nursing home for an ascending sensory and motor neuropathy of unknown origin . He has a history of stage four chronic kidney disease , treatment-resistant hypertension , type 2 diabetes ,

Henry Gray / bit . ly / 3ojVAJd d Rupture of a thin fibrous atherosclerotic cap and superficial erosion of the intimal surface can lead to acute thrombosis .

4 . Which THREE are lifethreatening non-cardiac differential diagnoses of chest pain ? a ACS . b Aortic stenosis . c PE . d Aortic dissection .

5 . Which ONE of the following is NOT a classical feature of ischaemic pain ? a Retrosternal . b Intensity worsens with positional changes . c Radiation to the throat . d Deep , diffuse , and difficult to localise . previous NSTEMI about 14 years ago , with subsequent heart failure .

Investigations identify a vitamin B12 deficiency as the likely cause of subacute degeneration of the spinal cord , and he receives replacement B12 .

About two weeks into his admission , Stefan reports intermittent epigastric and right upper quadrant pain . Following surgical review , this is deemed secondary to cholelithiasis . These symptoms settle with conservative management . However , several days later , he reports severe chest pain , atypical in its description , radiating towards his back . The pain settles without intervention . An ECG reveals

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6 . Which THREE statements regarding the ECG in myocardial ischaemia are correct ? a ST-segment elevation indicates transmural ischaemia . b ST-segment depression and T wave inversion may indicate diffuse subendocardial ischaemia . c Evidence of ischaemia may be masked in the presence of severe left ventricular hypertrophy or left bundle branch block . d Major ECG change is always present in the presence of ischaemia .

7 . Which THREE conditions are associated with a high risk of developing cardiovascular disease ? a Renal disease .

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ACUTE CORONARY SYNDROME

sinus rhythm with a known left bundle branch block . Serial high sensitivity troponins ( troponin T ) are significantly elevated , rising from 197ng / L to 1045ng / L ( normal less than 15ng / L ).

Cardiology is consulted , and Stefan is administered a 48-hour heparin infusion and started on dual antiplatelet therapy with aspirin and clopidogrel . His troponins peak at 2783ng / L .

An echocardiogram reveals akinesis of the apical myocardium and hypokinesis of the mid-apical anteroseptal and inferoseptal myocardium . Systolic function of the left ventricle is moderately reduced with an estimated ejection fraction of 30-35 %.

b Osteoarthritis . c Familial hypertriglyceridemia . d Mental health disorders

8 . Which TWO are appropriate medications to provide in suspected ACS in the outpatient setting ? a Oral aspirin . b NSAIDs . c Anticoagulation . d Sublingual or spray GTN .

9 . Which THREE are secondary prevention strategies in those who survive and ACS ? a Healthy behaviours . b Regular assessment with stress testing of CTA . c Intensive risk factor modification . d Adherence to proven cardioprotective medications .

10 . Which THREE drug classes are recommended in elderly patients post ACS ? a Aspirin . b SGLT2 inhibitors . c Statins . d ACEIs or ARBs .

Because of the presence of a comitant urinary tract infection , an angiogram is delayed four days after the initial chest pain and is performed once his fever has settled . This demonstrates a 90 % stenosis in the diagonal branch of the left anterior descending artery , which was not amenable to a stent . Given his echocardiogram findings , Stefan is started on a low-dose bisoprolol and maintained on dual antiplatelet therapy .

Stefan discharges himself against medical advice , voicing a desire to spend as much time as possible with his close family and he also declines specialist follow-up . He agrees to follow up with his GP , with discussions directed towards identifying his goals of care and directing management in line with his wishes .

CONCLUSION

CAD is a leading cause of mortality worldwide . Presentations from this condition will continue to increase as the population ages . It is important that GPs are familiar and comfortable with its presenting features , initiate early acute management , and manage patients long-term after an ischaemic event .

While evidence in this field and recommendations and guidelines are rapidly changing , the essential skills are a thorough and targeted history and physical examination . Recognising high-risk features allows the GP to make appropriate referrals to acute care pathways . Long-term management and secondary prevention are critical in this cohort of patients who remain at high risk for further events .

RESOURCES

• EDACS bit . ly / 3yWq0Dj

• HEART score bit . ly / 3JXtJXH

• Marburg heart score bit . ly / 40pVU6R

• INTERCHEST Clinical Prediction Rule for Chest Pain in Primary Care bit . ly / 3TxgVui

References Available on request from howtotreat @ adg . com . au

Figure 10 . Anatomy of the coronary arteries .