Ischaemic Heart Disease (IHD)

Stable Angina

Features

•    Exertional chest pain or tightness

•    Relieved by rest or nitrates within minutes

•    Often predictable (fixed coronary stenosis)

Diagnosis

•    First-line: exercise ECG (if feasible)

•    Alternatives: myocardial perfusion imaging, stress echo, CT coronary angiogram

Management

•    Symptomatic relief:

o    Short-acting nitrates (GTN spray)

o    Beta-blockers (first-line)

o    Calcium channel blockers (if BB contraindicated)

•    Secondary prevention:

o    Antiplatelet (aspirin)

o    High-intensity statin (e.g., atorvastatin 80 mg)

o    BP control (ACE inhibitor if hypertensive/diabetic)

o    Lifestyle: smoking cessation, exercise, diet

Acute Coronary Syndromes (ACS)

STEMI

•    ECG: ST elevation ≥1 mm in 2 contiguous limb leads or ≥2 mm in precordial leads

•    Troponin rise

•    Pathology: complete occlusion → transmural infarct

Immediate treatment (MONA + PCI):

•    Morphine + antiemetic

•    Oxygen (if hypoxaemic)

•    Nitrates

•    Aspirin 300 mg + P2Y12 inhibitor (clopidogrel/ticagrelor)

•    Primary PCI within 120 min (preferred)

•    If PCI unavailable within time: fibrinolysis (e.g., tenecteplase)

NSTEMI

•    No ST elevation; may have ST depression/T wave inversion

•    Troponin rise (distinguishes from unstable angina)

•    Pathology: subendocardial infarction (partial occlusion)

Management:

•    Anti-ischemic therapy: nitrates, beta-blockers

•    Dual antiplatelet therapy (DAPT)

•    Anticoagulation: fondaparinux or LMWH

•    Risk stratification (e.g., GRACE score) to decide early angiography

Unstable Angina

•    No ST elevation, troponin negative

•    New-onset, worsening, or at rest

•    Managed similarly to NSTEMI

Secondary Prevention Post-ACS

•    DAPT: aspirin + P2Y12 inhibitor (at least 12 months)

•    High-intensity statin

•    Beta-blocker (unless contraindicated)

•    ACE inhibitor (improves survival)

•    Lifestyle: smoking cessation, weight/BP/glucose control, cardiac rehab

Silent Ischaemia

•    Common in diabetics and elderly

•    May present with breathlessness, fatigue, or incidental ECG changes

•    Important to consider in atypical presentations

Extra Revision Pearls

•    STEMI clue → "tombstone" ST elevation; PCI within 120 min is best

•    NSTEMI clue → troponin +ve, no ST elevation

•    Unstable angina clue → new/worsening pain at rest, troponin –ve

•    Posterior MI clue → ST depression in V1–V3, tall R waves

•    Right ventricular MI clue → inferior STEMI + hypotension; avoid nitrates

•    Diabetics → silent ischaemia; look for subtle signs

•    ACE inhibitors improve post-MI survival (especially with LV dysfunction)

•    Long-term nitrates do not improve mortality; only symptoms