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Cardiology > Angina > Flashcards

Angina Flashcards

1
Q

What is stable angina pectoris?

A

https://www.youtube.com/watch?v=zD9aXZY0pdY

It is a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis

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2
Q

What percentage of coronary artery stenosis needs to be present for angina to occur?

A

>70%

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3
Q

What is the pathophysiology of stable angina?

A

A mismatch between the supply and demand of O2 and metabolites to the myocardium. This is primarily due to a reduction in coronary blood flow due to:

  • Obstructive coronary atheroma (very common)
  • Coronary artery Spasm (uncommon)
  • Coronary inflammation/arteritis (very rare)

It can also be due to anaemia of any cause and increased myocardial O2 demand:

  • LVH
  • Thyrotoxicosis

On activity, increased oxygen demand by the myocardium leads to myocardial ischaemia, and subsequently the symptoms of angina.

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4
Q

What are non-modifiable risk factors for the development of angina?

A
  • Age
  • Sex - male
  • Family history
  • Ethnicity/Race
  • Genetics
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5
Q

What are modifiable risk factors of angina?

A
  • Smoking
  • Physical inactivity
  • Hypertension
  • Dyslipidaemia
  • Diabetes mellitus
  • High calorie intake
  • Psychological stress
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6
Q

What is the difference between stable and unstable angina?

A

https://www.youtube.com/watch?v=zD9aXZY0pdY

Stable angina causes pain during exercise and stress, whereas unstable angina causes this as well as pain at rest (doesn’t go away).

Unstable angina is classed as one of the acute coronary syndromes

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7
Q

What are the symptoms experienced in someone with stable angina?

A

Symptoms present on exertion and relieved by rest

  • Chest pain
  • Dyspnoea
  • Nausea
  • Sweating
  • Faintness
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8
Q

What are characteristic features of chest pain experienced in those with stable angina?

A
  • Retrosternal pain - tight band across the chest/pressure
  • Radiates to the neck +/- jaw +/- arms
  • Worse on exertion or stress
  • Rapidly improved with GTN spray
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9
Q

When someone presents with chest pain, what would you want to distinguish?

A

Typicality of the chest pain

  • Anginal - Typical, atypical
  • Non-anginal - Gastro, Respiratory, MSK, Pschological
  • ACS?

https://pathways.nice.org.uk/pathways/chest-pain/assessing-and-diagnosing-suspected-stable-angina#content=view-node%3Anodes-assess-the-typicality-of-chest-pain

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10
Q

What systems would you consider as part of a differential diagnosis for chest pain?

A
  • Cardiovascular
  • Respiratory
  • GI
  • MSK
  • Psychiatric
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11
Q

What are cardiac causes of chest pain?

A
  • ACS
  • Aortic dissection
  • Pericarditis
  • Stable angina
  • Endocarditis
  • Cardiac tamponade
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12
Q

What are respiratory causes of chest pain?

A
  • PE
  • Pneumothorax
  • Pneumonia
  • Lung Cancer
  • Bronchiectasis
  • Pleural disease - pleurisy
  • Pulmonary hypertension
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13
Q

What are GI causes of chest pain?

A
  • Oesophageal spasm/rupture
  • GORD
  • Peptic ulceration
  • Acute pancreatitis
  • Cholecystitis
  • Biliary colic
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14
Q

What MSK problems could present with chest pain?

A
  • Rib fracture
  • Costochondritis
  • Muscle spasm/strain
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15
Q

What psychiatric problems can present with chest pain?

A
  • Anxiety
  • Panic attack
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16
Q

What signs might you see in someone with angina?

A

Evidence of risk factors

  • Tar staining
  • Obesity
  • Xanthalasma and corneal arcus
  • Hypertension
  • Arterial disease signs - AAA bruit, Absent peripheral pulses
  • Diabetic/hypertensive retinopathy
  • Pallor/anaemia
  • Hyperthyroid signs - tachycardia, tremor, hyper-reflexia
  • Signs of HF - basal crackles, elevated JVP, peripheral oedema
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17
Q

What are the following, and what are they a sign of?

A

Xanthalesmata - well demarcated, yellow plaques of cholesterol most often seen around the eyes. Caused by lipid abnormalities and other factors.

Seen in hyperlipidaemia, diabetes

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18
Q

What is the following, and what might it indicate?

A

Corneal arcus - may indicate the presence of hyperlipidaemia

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19
Q

If someone presented suffering from what seems like stable angina, what investigations would you consider as part of a full investigation for angina?

A

Intial

  • Bloods - FBC, Lipid profile, fasting glucose, U+Es, LFTs, TFTs
  • Consider CXR - other causes of Chest pain

First line diagnostic process - In NHS scotland

  • Baseline function - ECG + ETT
  • Myocardial perfusion scan - if unable to perform ETT
  • Coronary angiography - considered after non-invasive testing where patients are identified to be at high risk or where a diagnosis remains unclear.

Others to consider - not routinely used in NHS scotland

  • Stress echocardiography
  • Magnetic resonance perfusion imaging (MRI)
  • Multislice computed tomography (CT) scanning

http://www.sign.ac.uk/assets/sign96.pdf

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20
Q

Why would you do an FBC as part of your initial investigation of someone with stable angina?

A

Check for anaemia

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21
Q

Why would you do a lipid profile in someone with suspected stable angina?

A

Assess for hyperlipidaemia

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22
Q

Why would you do a fasting glucose in someone with suspected angina?

A

Check for diabetes - vascular risk factor

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23
Q

Why would you do TFTs in a person with suspected stable angina?

A

Look for thyrotoxicosis

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24
Q

Why might you do a CXR in someone with suspected stable angina?

A

Rule out other causes of chest pain

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25
Q

Why would you perform an ECG on someone with suspected stable angina?

A

To investigate for signs of ACS, previous MI, LVH or LBBB

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26
Q

What features on an ECG would indicate a previous MI?

A
  • Pathological Q waves - > 40 ms (1 mm) wide, > 2 mm deep, > 25% of depth of QRS complex
  • T-wave inversion
27
Q

What is an exercise tolerance test?

A

http://www.nhs.uk/video/pages/guide-to-an-exercise-ecg.aspx

Patient is put under stress on an exercise treadmill, whilst being hooked up to an ECG monitor. Depending on the type of test used, operators can accurately demostrate exercise induced angina, both through symptomatology and ECG changes

28
Q

What is Prinzmetal’s Angina?

A

Angina that occurs without provocation, usually at rest, as a result of coronary artery spasm. It occurs more commonly in women

29
Q

What are contraindications to ETT?

A
  • Recent Q wave MI or unstable angina
  • Severe aortic stenosis
  • Uncontrolled arrhythmia, HTN or HF
  • Acute myocarditis or pericarditis
  • Acute dissection
  • Acute PE
30
Q

In someone with PRinzmetal angina, what would you characteristically see on ECG?

A

ST elevation during painful episode

31
Q

What does a positive ETT indicate?

A

Indicates that there is a significant probability that there is IHD present - DOES NOT CONFIRM

32
Q

What is decubitus angina?

A

Angina precipitated by lying down

33
Q

What is the defintion of grade 1 angina based on the CCS criteria?

A

Ordinary physical activity does not cause angina, symptoms only on significant exertion.

34
Q

What is the defintion of grade II angina based on the CCS criteria?

A

Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs

35
Q

What is the defintion of grade III angina based on the CCS criteria?

A

Marked limitation, symptoms on walking only 1-2 blocks (50-100 yards) or 1 flight of stairs

36
Q

What is the definition of grade IV angina based on the CCS severity criteria?

A

Symptoms on any activity, getting washed/dressed causes symptoms

37
Q

When would you use a myocardial perfusion scan when investigating angina?

A

When ETT is not an option

38
Q

What is a myocardial perfusion scan?

A

A nuclear medicine procedure that illustrates the function of the heart muscle using thalium-201 (myocardium). It evaluates many heart conditions, such as coronary artery disease (CAD), hypertrophic cardiomyopathy and heart wall motion abnormalities. The function of the myocardium is also evaluated by calculating the left ventricular ejection fraction (LVEF) of the heart. This scan is done in conjunction with a cardiac stress test.

39
Q

What are the components to managing someone with stable angina?

A
  • Modify risk factors
  • Medications
40
Q

What lfiestyle factors would you seek to modify in someone with angina?

A
  • Stop smoking
  • Weight loss
  • Exercise
  • Control HTN and Diabetes (if present)
41
Q

What dose of aspirin would you give someone with stable angina?

A

75 mg/24 hrs

42
Q

What is typical angina?

A

Characterised by 3 core symptoms

  • Constricting discomfort in front of chest, arms, neck, jaw
  • Exertional chest pain
  • Relieved by rest or GTN
43
Q

What is atypical angina?

A

Characterised by 2/3 of core anginal symptoms

  • Constricting discomfort in front of chest, arms, neck, jaw
  • Exertional chest pain
  • Relieved by rest or GTN
44
Q

What medications would you give as secondary prevention in angina?

A
  • Aspirin
  • Statins
  • ACEi - for other risk factors e.g. hypertension
45
Q

What B-blockers would you consider giving?

A
  • Atenalol
  • Bioprolol
  • Metopralol
46
Q

When would B-blockers be contraindicated?

A
  • Asthma
  • COPD
  • Bradycardia
  • LVF
  • Coronary artery spasm
47
Q

What calcium channel blockers would you consider using in angina?

A
  • Verapimil
  • Diltiazem
  • Amlodipine
48
Q

What mnemonic could you use for the overall management of angina?

A
  • Aspirin and anti-anginals
  • Beta-blockers and Blood pressure
  • Cigarette smoking and cholesterol
  • Diet and diabetes
  • Exercise and Education
49
Q

When would you consider using 2nd line anti-anginals such as Ivabridine or Nicroandil?

A

Both B-blockers or CCBs not tolerated or contraindicated

50
Q

When would Percuatneous Coronary Angioplasty be indicated for in angina?

A
  • Poor rsponse to medication
  • Not suitable for CABG/have already had CABG
  • Post thrombolysis with severe stenosis
  • Positive stress test
51
Q

When would a CABG be indicated in angina?

A

Diffuse multi-vessel disease

52
Q

What are the most commonly used vessels in CABG procedures?

A
  • Veins - Long saphenous vein
  • Arteries - Internal MA, gastro-epiploic, inferior epigastric, radial artery
53
Q

Which is a more risky procedure; CABG or PCI?

A

CABG

54
Q

What are complications of PCI?

A
  • Restenosis within 6 months (20-30%)
  • Emergency CABG (<3%)
  • MI (<2%)
  • Death (0.1%)
55
Q

What are first line anti-anginal medicaitons?

A
  • B-blockers
  • Non-dihydropiridine CCBs and Amlodipine

GTN - used as a reliever

56
Q

What medications are used as second line anti-anginals?

A
  • Long acting nitrates - isosorbide mononitrate
  • Nicorandil
  • Ivabridine
  • Ranolazine
57
Q

What is the rule of thumb when treating someone with acute sudden onset chest pain?

A

Treat as ACS until proven otherwise

58
Q

When would you consider doing a CABG over a PCI intervention?

A
  • Calcified lesion in tortuous vessel
  • LAD disease
  • Strongly positive ETT
59
Q

What is cardioplegia?

A

Where the heart is stopped manually during an operation. Involves cooling heart to 34 oC, before injecting cardioplegic solution into coronary circulation

60
Q

What are complications of CABG?

A
  • MI - 2%
  • Ventricular arrhythmias
  • Stroke
  • Bleeding
61
Q

If someone could not tolerate B-blockers or CCBs, what treatment is available?

62
Q

If someone was on a monotherapy of B-blocker or CCB, their angina was uncontrolled, and the other option (B-blocker/CCB) was contraindicated, what options are available?

63
Q

When would you consider revasularisation in someone with stable angina?

A

If they had uncontrolled symptoms on 2 or more anti-anginal medications

Cardiology (29 decks)

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