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3: MED1 Y3 - Cardiovascular [2] > [18] Angina > Flashcards

[18] Angina Flashcards

1
Q

What is angina also known as?

A

Angina pectoris

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2
Q

What is angina?

A

Chest pain or pressure, usually due to not enough blood flow reaching the heart muscle

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3
Q

What does angina result from?

A

The demands of the myocardium not being met by blood supply, which usually implies narrowing of one or more of the coronary arteries

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4
Q

When does angina tend to occur?

A

At times the heart has to do more work, e.g. exercise or emotional stress

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5
Q

Is angina life threatening?

A

No

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6
Q

Why is angina clinically important?

A

It is a warning sign the patient could be at risk of a heart attack or stroke

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7
Q

What are the respiratory causes of chest pain?

A
  • Pneumonia
  • Pulmonary embolism
  • Pneumothorax
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8
Q

What are the GI causes of chest pain?

A
  • GORD
  • Peptic ulcer disease
  • Biliary colic or cholecystitis
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9
Q

What are the MSK causes of chest pain?

A
  • Fractures or bone metastases to ribs
  • Muscular problems of the chest wall
  • Skin problems
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10
Q

What are the CVS causes of chest pain?

A
  • Angina
  • MI
  • Pericarditis
  • Aortic dissection
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11
Q

What is angina usually caused by?

A

Atheroma

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12
Q

What can angina rarely be caused by?

A
  • Anaemia
  • Coronary artery spasm
  • Aortic stenosis
  • Tachyarrhythmia’s
  • Arteritis/small vessel disease
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13
Q

What is the leading cause of heart attacks?

A

Coronary heart disease

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14
Q

What is coronary heart disease?

A

A condition where the coronary arteries become occluded with cholesterol plaques

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15
Q

What happens when a plaque builds up in the arteries?

A

It produces a condition called atherosclerosis

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16
Q

What can happen to atherosclerotic plaques over many years?

A

They can harden or rupture

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17
Q

What effect can harded atheromatous plaques have?

A

They can narrow the coronary arteries, and cause reduced oxygenated blood flow to the heart, causing ischaemia and resulting in angina or heart attack

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18
Q

What can happen if an atheromatous plaque ruptures?

A

A blood clot can form on its surface, which might block the coronary arteries and cause ischaemic death of the myocardium

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19
Q

What are the modifiable risk factors for coronary heart disease?

A
  • Smoking
  • Diabetes mellitus and impaired glucose tolerance
  • Metabolic syndrome
  • Hypertension
  • Hyperlipidaemia
  • Obesity
  • Physical inactivity
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20
Q

What are the non-modifiable risk factors for coronary heart disease?

A
  • Increasing age
  • Being male
  • Family history of premature CHD
  • Premature menopause
  • South Asian ethnic group
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21
Q

What happens in stable angina?

A

Atheromatous plaques, with a necrotic centre and fibrous cap, build in the coronary vessels, occluding more and more of the lumen and leaving less space for the passage of blood, leading to ischaemia of the myocardium

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22
Q

How much of the lumen must be occluded for angina to occur?

A

70%

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23
Q

What causes progression of stable angina to unstable angina?

A

Progression of the atheromatous plaque leading to increased occlusion of the lumen

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24
Q

What are the symptoms of angina?

A
  • Typical ischaemic chest pain
  • Breathlessness
  • Nausea
  • Fatigue
  • Dizziness
  • Restlessness
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25
Where might the ischaemic chest pain spread in angina?
* Neck * Jaw * Back * Left arm
26
What symptoms make a diagnosis of angina less likely?
* Continuous pain * Pleuritic pain * Pain that is worse with swallowing * Pain associated with palpitations * Dizziness or tingling
27
What is the difference between stable and unstable angina?
* Stable angina only occurs in response to triggers. Unstable angina occurs at rest, or with minimal exertion * Stable angina can be relieved by rest or medication * Stable angina is described as mild to moderate pain. Unstable angina is severe
28
What can trigger stable angina?
* Exertion * Emotion * Eating * Cold weather
29
Of what pattern is the pain in unstable angina?
Crescendo (distinctly more severe, prolonged, or frequent than before)
30
What investigations are done in a patient with angina?
* ECG and exercise ECG * Blood tests * Chest x-ray * Echo * Angiography * Functional imaging
31
What functional imaging may be done in angina?
* Myocardial perfusion scintigraphy * Stress echo * Cardiac MRI
32
What does the ECG show in angina?
It is usually normal, but may show ST depression, flat or inverted T waves, or signs of a previous MI
33
What blood tests are done in angina?
* FBC * U&E * TFTs * Lipids * HbA1c
34
What is involved in the management of angina?
* Address exacerbating factors * Secondary prevention of cardiovascular disease * Symptomatic relief * Anti-anginal medications * Revascularisation
35
What exacerbating factors should be addressed in angina if present?
* Anaemia * Tachycardia * Thyrotoxicosis
36
What is involved in the secondary prevention of cardiovascular disease in angina?
* Stop smoking * Exercise * Dietary advice * Optimise hypertension and diabetes control * 75mg/day of aspirin if not contraindicated * Address hyperlipidaemia * Consider ACE inhibitors
37
How is symptomatic relief achieved in angina?
Glyceryl trinitrate (GTN) spray or sublingual tablet
38
What should the patient do if GTN spray/tablet does not relieve their angina symptoms?
Repeat the dose if the pain has not gone in 5 minutes. Call an ambulance if the patient is still present 5 minutes after the second dose
39
What is GTN?
A moderately volatile organic nitrate which is used in the treatment of angina pectoris
40
What does GTN spray cause?
A rapid reduction in myocardial oxygen demand, followed by rapid relief of symptoms
41
Is GTN spray effective in stable or unstable angina?
Both
42
What is the mechanism of action of GTN spray?
Nitrates inhibit coronary vasoconstriction or spasm, increasing perfusion of the myocardium, and therefore relieving vasospastic angina. Additionally, they cause venodilation, decreasing preload and myocardial oxygen consumption
43
What is the most common adverse effect of GTN spray?
Headache
44
What can high doses of GTN spray cause?
* Postural hypotension * Facial flushing * Tachycardia
45
Does tolerance to nitrates build up?
Yes, quickly
46
Why does tolerance to nitrates develop rapidly?
Because the blood vessels become desensitised to vasodilation
47
How can tolerance to nitrates be overcome?
Providing a daily 'nitrate-free interval' for 10-12 hours, usually at night
48
What is the onset of action of nitrates?
Around 1 minute
49
What is the duration of action of nitrates?
Around 25 minutes
50
Do nitrates undergo first-pass metabolism in the liver?
Yes, significantly
51
How are the effects of first-pass metabolism of nitrates avoided?
By giving spray sublingually or as a spray
52
What is the first-line treatment for stable angina?
Either a ß-blocker or a calcium channel blocker
53
What should the choice between ß-blocker and calcium channel blocker in angina be made based on?
* Co-morbidities * Contraindications * Person's preference
54
What should be done if either first-line agent in stable angina is intolerable or ineffective?
Switch to the other
55
What should be done if the first-line agent in the treatment of stable angina is insufficient?
Consider adding another drug
56
What addition drug can be added to first-line treatments in stable angina?
* Isosorbate mononitrate * Ivabradine * Nicorandil * Ranolazine
57
When should a third anti-anginal drug be added in stable angina?
If the person's symptoms are not satisfactorily controlled with two anti-anginal drugs, and they are either waiting for revascularisation, or revascularisation is not appropriate
58
What is isosorbate mononitrate?
An organic nitrate
59
How does isosorbate mononitrate differ from GTN spray in terms of physical properties?
It is solid at room temperature
60
How is isosorbate mononitrate the same as GTN spray?
Same mechanism of action and adverse effects
61
What is the onset of action of isosorbate mononitrate?
30 minutes
62
What is the duration of action of isosorbate mononitrate?
12 hours
63
What is isosorbate mononitrate used for?
The prophylactic treatment of angina
64
When is revascularisation considered in angina?
When optimal medical therapy has failed
65
What are the options for revascularisation in angina?
* Percutaneous coronary intervention * CABG

3: MED1 Y3 - Cardiovascular [2] (19 decks)

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