Angina

Question 1

what is the definition of angina?

Answer 1

• Angina is chest pain or discomfort as a result of reversible myocardial ischaemia
• This usually implies narrowing of one or more of the coronary arteries
• Tends to be exacerbated by exertion and relieved by rest
Can be stable, unstable or prinzmetal’s

Question 2

what is the epidemiology of angina?

Answer 2

• More common in men

- 10 year lag for women

Question 3

what is the aetiology of angina?

Answer 3

Atherosclerosis
Diabetes, hypertension, hypercholesterolaemia
Myocardial ischaemia resulting in angina occurs when there is a mismatch between blood supply and metabolic demand - this can occur due to:
• Atheroma/stenosis of coronary arteries thereby impairing blood flow - most common cause
• Valvular disease
• Aortic stenosis
• Arrhythmia
• Anaemia - thus less O2 can be transported
- Ischaemic metabolites including adenosine, stimulate nerve endings and produce pain

Question 4

what are the risk factors of angina?

Answer 4

• Smoking
• Sedentary lifestyle
• Obesity
• Hypertension
• Diabetes mellitus
• Family history
• Genetics
• Age
• Hypercholesterolaemia (high LDL and low HDL)
• drug use
• male

Question 5

what is the pathophysiology of angina?

Answer 5

atherosclerosis formation
-fatty streak
-intimal cell mass
-plaque
-plaque rupture
A traditional model suggests two means of plaque progression. Large thick-walled plaques are thought to slowly obstruct the lumen of coronary arteries, thereby causing decreased perfusion and chronic intermittent exertional symptoms when they reach 70% to 80% stenosis. Thin-walled 'vulnerable plaques' may not cause meaningful obstruction until the wall is disrupted, at which point acute haematoma and thrombus formation cause sudden myocardial infarction by occluding the arterial lumen locally or embolising distally into the coronary circulation. This model explains two clinically important phenomena: 1) myocardial infarction may occur in patients at anatomical sites without baseline flow limitation; 2) therapies that reduce chronic intermittent angina (improve flow) may be different from those that reduce ischaemic heart disease mortality (stabilise plaque, prevent thrombosis).

Question 6

what are the key presentations of angina?

Answer 6

• central chest tightening and heaviness
• pain from exertion lasting less than 20 mins (low risk unstable angina)
• presence of risk factors
  normal examination

Question 7

what are the signs of angina?

Answer 7

• presence of risk factors
• normal examination
• known medical history of exacerbating factor

Question 8

what are the symptoms of angina?

Answer 8

Tightness and heaviness provoked by exertion, especially after a meal or in the cold and wind.
Relieved by rest
Pain may radiate to arms, neck, jaw or teeth
Dyspnoea, nausea, sweating and faintness

Question 9

what are the 1st line and gold standard investigations for angina?

Answer 9

- 12 lead ECG: 
• Often normal 
• May show ST depression 
• Flat or inverted T waves 
• Look for signs of past MI
- haemoglobin - may be anaemia 
- lipid profile - elevated LDL cholesterol is associated with increased risk; elevated HDL is protective
- fasting blood glucose - elevated in diabetes

score pain:
• 1. Have, central, tight, radiation to arms, jaw & neck 
• 2. Precipitated by exertion 
• 3. Relieved by rest or spray GTN 
• 3/3 = Typical angina 
• 2/3 = Atypical pain 
• 1/3 = Non-anginal pain

Question 10

what other tests could be done for angina?

Answer 10

Treadmill test/Exercise ECG:
• Put ECG on patient, then make them run on treadmill uphill - trying to induce ischaemia
• Monitor how long patient is able to exercise for
• If you see ST segment depression then this is a sign of late-stage ischaemia
• Many patients unsuitable e.g. can’t walk, very unfit, young females and bundle branch block
CT Scan Calcium scoring:
• CT the heart and if there is atherosclerosis in the arteries then the calcium will light up white - if there is significant calcium then this would indicate angina
CXR
TSH levels

Question 11

what are the differential diagnoses for angina?

Answer 11

• Pericarditis/myocarditis
• Pulmonary embolism
• Chest infection
• Dissection of the aorta
• GORD

Question 12

how is angina managed?

Answer 12

-modifying risk factors
-medication
aspirin, statins, beta blockers, calcium channel blockers
-coronary artery bypass graft

Question 13

how is angina monitored?

Answer 13

heart monitoring, medication reviews

Question 14

what are the complications of angina?

Answer 14

stroke , MI, unstable angina, sudden cardiac death, anxiety, depression, reduced quality of life, heart failure

Question 15

what is the prognosis of angina?

Answer 15

Annual mortality rate of 1.4%. Women tend to have worse prognosis