Angina

Question 1

Angina pathophysiology

Answer 1

Atherosclerosis can partially occlude caronary artery, decreasing teh blood supply to the heart.

When exercising, diastole time decreases therefore there is less time to perfuse the heart.

Pain during exertion as cannot meet cardiac oxygen requirements but relieved by rest

Question 2

Aetiology

Answer 2

Mostly atheroma
Anaemia
Aortic stenosis
Tachyarrhythmias

Question 3

Risk factors

Answer 3

Modifiable:
• HTN
• DM
• Smoking
• ↑cholesterol
• Obesity

Non-modifiable:
• Age
• Male
• FH (MI < 55yrs)
• Genetic: e.g. hyperlipidaemia

Question 4

Symptoms

Answer 4

• Central chest tightness or heaviness
• Brought on by exertion, relieved by rest
• May radiate to one/both arms, neck, jaw or teeth
• Other precipitants: emotion, cold weather, heavy meals

Question 5

Investigations

Answer 5

Ix
•  Bloods: FBC, U+E, lipids, glucose, ESR, TFTs, Trop I
•  ECG: usually normal
• Consider exercise ECG
• Stress echo
• Perfusion scan
•  Angiography (gold standard)

Question 6

Conservative Management of angina

Answer 6

Lifestyle:
• Stop smoking
• Wt. loss and ↑ exercise
• Healthy diet: oily fish, fruit, veg, ↓ sat fats

Question 7

Ivabridine

Answer 7

Blocks funny current in SAN

Question 8

When to do PCI

Answer 8

Poor response to medical Tx

Refractory angina but not suitable for coronary artery bypass graft

Question 9

Coronary artery bypass graft indications

Answer 9

Left main stem disease
Triple vessel disease
Refractory angina
Unsuccessful angioplasty

Question 10

CCU admission

Answer 10

1. Assessment, diagnosis and treatment of patients with acute myocardial infarction and other
   acute coronary syndromes
2. Patients with haemodynamically significant brady- or tachy-arrhythmia
3. Acute cardiogenic pulmonary oedema with haemodynamic compromise
4. Cardiogenic shock
5. Drug overdose associated with life-threatening arrhythmia
6. Confirmed pulmonary embolism with haemodynamic compromise, being considered for
   thrombolysis

Question 11

Secondary prevention Mx

Answer 11

Medical:
Secondary prevention of  cardiovascular events:
•  Aspirin 75mg OD
•  ACEi (esp. DM)
•  Statins: simvastatin 40mg
•  Antihypertensives

Question 12

Medical Mx of angina

Answer 12

1. GTN + either:
   - 1st: β blocker
   - 2nd: CCB - Verapamil if monotherapy
   Nifedipine is used if with Beta blocker

• 3rd: Isosorbide mononitrate
• 4th: Ivabradine

Question 13

Nitrate tolerance

Answer 13

When taking standard release isosorbide mono nitrate use asymmetrical dosing intervals to maintain a nitrate free time of 10 - 14 hours

Minimise tolerance