Angina Flashcards
What are the two main causes of angina?
Low myocardial oxygen supply
High myocardial oxygen deman
For what reasons may myocardial oxygen supply be low?
Coronary artery disease - atherosclerosis
Severe anaemia
For what reasons may myocardial oxygen demand be high?
LV hypertrophy
RV hypertrophy
Rapid tachyarrhythmias
Why might you get LV hypertrophy?
hypertension
aortic stenosis
aortic regurg
Hypertrophic cardiomyopathy
Why might you get RV hypertrophy?
Pulmonary hypertension
Pulmonary stenosis
When might you need to refer a patient to a specialist in regards to angina?
worsening angina in patient with previously stable symptoms
new/recurrent angina when patient has history of MI or coronary revascularisation
occupational fitness assessment needed
atypical symptoms
new onset angina
What are the main things to look at when diagnosing angina?
HISTORY! character location radiation duration provocation
What is the diagnostic challenge with angina?
It is usually a manifestation of coronary artery disease so need to determine whether patient has chest pain WITH flow limiting coronary obstructions or not
How do you manage the challenge of angina diagnosis?
Functional testing for ischemia - stress echo
Anatomical testing for evidence of obstructive disease - CT Coronary Angiography
What are the 3 characteristics for typical angina?
central chest discomfort last 5-15 mins
provoked by exertion or emotional stress
relieved by rest/nitrates
What should be done if only 1 or less than 1 characteristics are present in the patient?
No diagnosis is needed
What to do if 2 or 3 characteristics are present?
CTCA diagnostic testing
or functional imaging
What are some symptom relief drugs/methods which can increase oxygen delivery?
increase coronary flow - nitrates, Calcium blockers, nicorandil which is a vasodilator, revascularisation
What are some symptom relief drugs which can reduce oxygen demand through reducing heart rate?
beta blockers, ivabradine (newer drug)
What drugs can be given in prevention to those who have already experienced angina?
aspirin statins (mainly those 2) ACE inhibitors P2Y12 receptor antagonists
What is the main procedure that can be done to repair coronary vasculature?
Coronary revascularisation
What are the main things to consider when thinking about coronary revascularisation?
Prognostic benefit Repeat revascularisation Symptomatic benefit Coronary anatomy Patient choice Procedural risk - stroke, death, AMI
What are the key assessments for chest pain?
How long have they had pain? (if it for 10 years or more it is unlikely to be because of the heart) How long does pain last? Where is it localised? What is the pain like? What provokes/relieves the pain?
How is ischemia testing done?
Exercise to increase heart rate so that when ischemia kicks in you can carry out perfusion imaging of coronary arteries. You can then see the LV wall motion to see how the heart contracts and ischemia will mean some parts of the wall will stop contracting, finally ECG’s to look at ST segments, and history!
What is ETT? How effective is it in comparison to CTCA?
Exercise Tolerance Testing, more false negatives than CTCA which is bad when you are testing for a serious disease as don’t want to miss it out
What are the ways to reduce oxygen demand?
decrease heart rate
reduce LV wall tension
reduce contractility
modify energy metabolism
What are some symptom relief drugs which can reduce oxygen demand through lowering LV wall tension?
beta blockers, nitrates, nicrorandil, calcium blockers, ranolazine
What are some symptom relief drugs which can reduce oxygen demand through reducing contractility?
beta blockers, calcium blockers
modify energy metabolism - trimetazidine
What are the NICE guidelines for angina treatment?
β blocker ± CAB (calcium channel blocker)
sublingual GTN (glyceryl trinitrate spray which works to dilate blood vessels)
aspirin, statin, ±ACE-I
lifestyle modification
What should you do if there is no further angina after the first treatment is given?
No further treatment Discuss with patient: prognosis likelihood of high risk anatomy benefits/risks of CABG
What should you do if after treatment there is still continuing angina?
Revascularisation after discussing with the MDT
Then if that does not work - coronary bypass surgery which is usually more effective.
How is coronary bypass usually done?
Using saphenous vein or using internal mammary artery
What is revascularisation?
It means to restore the blood supply to the coronary arteries. There is angioplasty where a balloon is used to widen the narrowed arteries or there is bypass where a vessel is taken from another part of the body and inserted to replace the damaged one.
