angina

Question 1

define

Answer 1

Angina is described as a clinical syndrome of chest pain or pressure that accompanies periods of myocardial ischaemia; it is usually the manifestation of CAD

It is usually aggravated by activities which increases myocardial demand for oxygen e.g. - exercise and emotional stress

Question 2

There are six main anginal syndromes:

Answer 2

1. chronic stable angina
2. nocturnal angina
3. unstable angina
4. variant angina (Prinzmetal’s)
5. decubitus angina
6. syndrome X

Question 3

chronic stable angina

Answer 3

Pain is provoked by physical exertion, especially after a meal, in cold weather or walking against the wind.

The pain is often also aggravated by anger or excitement.

The pain is relieved within 2-10 min by rest. Occasionally the pain will disappear even though exertion continues.

Often angina will be precipitated by a predictable degree of exertion in a particular patient; the threshold for pain varies widely between patient.

The severity of the symptoms is not closely related to the extent of coronary artery disease, indeed periods of ischaemia and myocardial infarction may be entirely painless.

The pain is often more easily provoked in the morning.

Question 4

Nocturnal angina

Answer 4

Nocturnal angina wakes a patient from sleep and may be provoked by vivid dreams.

Symptoms are commonest in the early hours of the morning when coronary artery tone is maximal.

The patient often has critical CAD and hence usually suffers from exertional angina.

Nocturnal angina may be associated with coronary artery spasm - Prinzmetal’s angina.

Question 5

unstable angina

Answer 5

UA is defined as recurrent episodes of angina on minimal effort or at rest.

It may be the initial presentation of IHD, or it may represent the abrupt deterioration of a previously stable anginal syndrome.

UA is also described as crescendo angina, preinfarction angina, and intermediate chest pain syndrome.

= one of the possible presentations of acute coronary syndrome

= is provoked more easily and persists for longer than stable angina.

Question 6

prinzmetal angina

Answer 6

This is angina caused by focal spasm of angiographically normal coronary arteries. In about 75% of patients there is also atherosclerotic coronary artery obstruction. In cases where there is atherosclerotic obstruction the vasospasm occurs near the stenotic lesion.

The chest pain may:

• occur at rest or wake the patient from sleep
• be accompanied by dyspnoea and/or palpitations
• be triggered by exertion; there is variability in the workload required to precipitate pain

The management of variant angina resembles that for other forms of angina. Nifedipine and nitrates are particularly effective (2).

Coronary stenting can be useful for refractory spasm, CABG can be used for important coronary atherosclerosis (2).

Once treated the prognosis is excellent and severe complications such as arrhythmias, myocardial infarction or sudden death are rare (2).

Question 8

Decubitus angina

Answer 8

occurs when the patient lies down. It is usually a complication of cardiac failure due to the strain on the heart resulting from the increased intravascular volume.

Patients usually have severe coronary artery disease.

Question 9

sydrome x [angina]

Answer 9

term syndrome x is used to describe the combination of angina-like chest pain, positive objective evidence of myocardial ischaemia (eg radionucleide perfusion scan) with a normal coronary angiogram

seen most frequently in women often in the early menopausal years

NICE state with respect to Cardiac syndrome X:

in people with angiographically normal coronary arteries and continuing anginal symptoms, consider a diagnosis of cardiac syndrome X.

continue drug treatment for stable angina only if it improves the symptoms of the person with suspected cardiac syndrome X

do not routinely offer drugs for the secondary prevention of cardiovascular disease to people with suspected cardiac syndrome X.

Question 10

s/s of angina

Answer 10

Angina is often a clinical diagnosis:

atypical presentation is frequently seen in women than in men, in older patients than in younger patients and in patients with diabetes

• angina is typically a tight, dull or heavy discomfort often seen retrosternally or left side of the chest
• the pain is usually not sharp or stabbing in character and is not influenced by respiration or relieved by antacids and simple analgesia
• there is usually some association with exertion or emotional stress; rest brings relief within a few minutes:
• discomfort may radiate to arms, neck, jaw or back (2)
• additional precipitants include:

1. cold weather
2. heavy meals
3. emotion (3)

nitrates typically offer rapid relief

pain may be associated with atypical symptoms such as fatigue or faintness, nausea, burping, restlessness or a sense of impending doom. These atypical symptoma are more likely to be seen in women, older patients and in diabetic patients

Question 11

o/e

Answer 11

there may be signs of conditions which precipitate angina

anaemia - pallor

thyrotoxicosis - resting tachycardia, tremor, and goitre

hypertension:

the blood pressure should be documented

displaced apex beat and fourth heart sound if there is left ventricular hypertrophy

hypercholesterolaemia:

xanthelasma and xanthoma

smoking:

nicotine stains

diabetes:

retinopathy

neuropathy