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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
Q

Where might the ischaemic chest pain spread in angina?

A
  • Neck
  • Jaw
  • Back
  • Left arm
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26
Q

What symptoms make a diagnosis of angina less likely?

A
  • Continuous pain
  • Pleuritic pain
  • Pain that is worse with swallowing
  • Pain associated with palpitations
  • Dizziness or tingling
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27
Q

What is the difference between stable and unstable angina?

A
  • 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
Q

What can trigger stable angina?

A
  • Exertion
  • Emotion
  • Eating
  • Cold weather
29
Q

Of what pattern is the pain in unstable angina?

A

Crescendo (distinctly more severe, prolonged, or frequent than before)

30
Q

What investigations are done in a patient with angina?

A
  • ECG and exercise ECG
  • Blood tests
  • Chest x-ray
  • Echo
  • Angiography
  • Functional imaging
31
Q

What functional imaging may be done in angina?

A
  • Myocardial perfusion scintigraphy
  • Stress echo
  • Cardiac MRI
32
Q

What does the ECG show in angina?

A

It is usually normal, but may show ST depression, flat or inverted T waves, or signs of a previous MI

33
Q

What blood tests are done in angina?

A
  • FBC
  • U&E
  • TFTs
  • Lipids
  • HbA1c
34
Q

What is involved in the management of angina?

A
  • Address exacerbating factors
  • Secondary prevention of cardiovascular disease
  • Symptomatic relief
  • Anti-anginal medications
  • Revascularisation
35
Q

What exacerbating factors should be addressed in angina if present?

A
  • Anaemia
  • Tachycardia
  • Thyrotoxicosis
36
Q

What is involved in the secondary prevention of cardiovascular disease in angina?

A
  • Stop smoking
  • Exercise
  • Dietary advice
  • Optimise hypertension and diabetes control
  • 75mg/day of aspirin if not contraindicated
  • Address hyperlipidaemia
  • Consider ACE inhibitors
37
Q

How is symptomatic relief achieved in angina?

A

Glyceryl trinitrate (GTN) spray or sublingual tablet

38
Q

What should the patient do if GTN spray/tablet does not relieve their angina symptoms?

A

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
Q

What is GTN?

A

A moderately volatile organic nitrate which is used in the treatment of angina pectoris

40
Q

What does GTN spray cause?

A

A rapid reduction in myocardial oxygen demand, followed by rapid relief of symptoms

41
Q

Is GTN spray effective in stable or unstable angina?

A

Both

42
Q

What is the mechanism of action of GTN spray?

A

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
Q

What is the most common adverse effect of GTN spray?

A

Headache

44
Q

What can high doses of GTN spray cause?

A
  • Postural hypotension
  • Facial flushing
  • Tachycardia
45
Q

Does tolerance to nitrates build up?

A

Yes, quickly

46
Q

Why does tolerance to nitrates develop rapidly?

A

Because the blood vessels become desensitised to vasodilation

47
Q

How can tolerance to nitrates be overcome?

A

Providing a daily ‘nitrate-free interval’ for 10-12 hours, usually at night

48
Q

What is the onset of action of nitrates?

A

Around 1 minute

49
Q

What is the duration of action of nitrates?

A

Around 25 minutes

50
Q

Do nitrates undergo first-pass metabolism in the liver?

A

Yes, significantly

51
Q

How are the effects of first-pass metabolism of nitrates avoided?

A

By giving spray sublingually or as a spray

52
Q

What is the first-line treatment for stable angina?

A

Either a ß-blocker or a calcium channel blocker

53
Q

What should the choice between ß-blocker and calcium channel blocker in angina be made based on?

A
  • Co-morbidities
  • Contraindications
  • Person’s preference
54
Q

What should be done if either first-line agent in stable angina is intolerable or ineffective?

A

Switch to the other

55
Q

What should be done if the first-line agent in the treatment of stable angina is insufficient?

A

Consider adding another drug

56
Q

What addition drug can be added to first-line treatments in stable angina?

A
  • Isosorbate mononitrate
  • Ivabradine
  • Nicorandil
  • Ranolazine
57
Q

When should a third anti-anginal drug be added in stable angina?

A

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
Q

What is isosorbate mononitrate?

A

An organic nitrate

59
Q

How does isosorbate mononitrate differ from GTN spray in terms of physical properties?

A

It is solid at room temperature

60
Q

How is isosorbate mononitrate the same as GTN spray?

A

Same mechanism of action and adverse effects

61
Q

What is the onset of action of isosorbate mononitrate?

A

30 minutes

62
Q

What is the duration of action of isosorbate mononitrate?

A

12 hours

63
Q

What is isosorbate mononitrate used for?

A

The prophylactic treatment of angina

64
Q

When is revascularisation considered in angina?

A

When optimal medical therapy has failed

65
Q

What are the options for revascularisation in angina?

A
  • Percutaneous coronary intervention
  • CABG

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

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