ANGINA Flashcards
Definition
Central/substernal heavy/tight/gripping chest pain that may radiate to jaw or arms caused by myocardial ischemia due to imbalance between blood supply and oxygen demand.
Stable Angina (6)
- Chest pain on exertion/emotion/stress
- Tight squeezing chest pain that lasts 5-15 mins, gradual in onset
- No pain at rest
- Occurs when oxygen demand exceeds perfusion (demand > supply)
- Constant; same effort/duration
- Relieved by rest or GTN within minutes
Unstable Angina (7)
- Chest pain at rest
OR - Crescendo/deterioration in previously stable angina
OR - Angina of recent onset (<24h)
- Due to reduced resting coronary blood flow, not due to increased demand
- Usually >15mins, not relieved by rest
- No ST elevation, normal cardiac enzymes
- Part of Acute Coronary Syndrome:
(ruptured atherosclerotic plaque leading to coronary occlusion)
Work up (6)
- Blood tests
- Chest X-ray
- Resting ECG
- Holter monitoring
- Stress test
- Echocardiography
Blood Tests (4)
- CBC, coagulation profile
- Lipid profile, fasting glucose, HbA1C
- TFT, RFT
- Troponin (done to exclude MI in unstable angina; should be negative)
Resting ECG (3)
Usually normal. May show ST depression and T-wave inversion during attack. Normal between attacks.
Holter monitor
To detect silent ischemia (diabetics/elderly)
Stress Test (6)
- Done if normal ECG
- If unstable angina —> must be stabilized with medical treatment before stress testing due to risk of adverse events (done 1 month after episode)
- Exercise-induced stress is preferred; if unable —> pharmacologic stress test
- A positive ECG stress test reveals ST segment depression
- Indications for angio:
- severe angina or ischemic changes
- ST depression >1mm at a low workload within 6 minutes, or a paradoxical fall in BP with exercise
- If there are baseline ECG changes (e.g. LBBB) —> myocardial perfusion scan (IV administration of Thallium/Technetium)
Echocardiography
If stress Echocardiography is positive for ischemia it would reveal wall motion abnormalities
Treatment of Stable Angina: Anti-anginal symptoms: (3)
- BB (preferred initial): decreased contractility, HR, O2 demand —> prolonged diastole and increased coronary perfusion
- Short-acting nitrates for immediate angina relief (GTN)
- CCB (dihydropyridines) and long-acting nitrates
- Alternatives if BB are contraindicated or have intolerable SEs
- May be add on if monotherapy is not successful
- Avoid CCB if low EF
Treatment of Stable Angina: Decreased incidence of adverse cardiovascular events (MI, death): (2)
- Aspirin and statins given to all patients
- Smoking cessation, BP control, weight control, exercise, optimal DM control
Treatment of Stable Angina: Revascularization in high risk patients (PCI/CABG) if:
- Low EF
- LAD/Left main/3-vessel disease
- Severe angina despite maximum medical therapy
Treatment of Unstable Angina (Acute Treatment): (8)
- Admit patient
- Oxygen (controversial, may only be given if <94)
- Morphine and nitrates (pain control)
- Dual antiplatelets (aspirin + clopidogrel)
- Beta blockers
- LMWH (enoxaparin) for 48 hours
- Electrolyte replacement (K+ and Mg++)
- Revascularization (controversial; indicated if no improvement after 48hours of medical therapy, or if hemodynamically unstable, or if new murmur).
Treatment of Unstable Angina (Maintenance Treatment): (5)
- Continue Aspirin and Clopidogrel for 6-9months, then Aspirin for life
- Beta blockers
- Nitrates (GTN)
- Statins (regardless of LDL level)
- Risk factors control (as above)
Variant/Prinzmental/Vasospastic Angina- Definition (3)
- Spontaneous episodes of angina with transient ischemic ST changes on ECG, due to severe spasm of an epicardial coronary artery, usually near an atherosclerotic lesion (—> transient, abrupt, marked reduction in the luminal diameter and transient myocardial ischemia)
- Chronic pattern of episodes of angina, predominately at rest, usually at night
- Usually in young smokers
