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Supporting life block > Angina > Flashcards

Angina Flashcards

1
Q

What are the symptoms of angina?

A
  • Tightness
  • Squeezing
  • Crushing sensation in the chest
  • Referred pain to left arm/left jaw
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2
Q

What is unstable angina?

A
  • Fibrous cap has been eroded
  • Very thrombotic plaque
  • doesnt follow a pattern
  • more severe
  • can occur with/without physical exertion at rest or medicine may not relieve the pain
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3
Q

What is atherosclerosis?

A
  • The build up of cholesterol rich plaques
  • The disease process leading to CHD
  • causes stenosis of coronary arteries
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4
Q

Describe the 2 components of an atherosclerotic plaque.

A
  1. ) Fibrous cap: SMCs and CT

2. ) Atheroma: soft pool of extracellular lipid, cell debris,activated immune cells. Progressively calcifies over time

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5
Q

What may thrombosis lead to?

A
  • unstable angina
  • STEMI
  • NSTEMI
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6
Q

What may cause angina?

A
  • exertion/emotion

- results from increased oxygen demand with restricted blood flow due to fixed stenosis

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7
Q

What may cause angina of effort?

A
  • exertion/emotion

- results from increased oxygen demand with restricted blood flow due to fixed stenosis

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8
Q

At which level of stenosis does angina develop?

A

-Stenosis of > or= 70%

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9
Q

How can decreased oxygen in cardiac tissue lead to coronary vasodilation?

A
  • The decrease in oxygen in the cardiac tissue results in a release of protons & bradykinin
  • This leads to activation of TRPV1 on sensory nerves which causes pain and the release of substance P
  • This subsequently leads to coronary vasodilation
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10
Q

What are the different types of angina?

A
  1. ) Angina of effort
  2. ) Mixed(variable threshold angina)
  3. ) Vasospastic(Prinzmetal’s) angina:
  4. ) Microvascular (syndrome X)
  5. ) Unstable
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11
Q

Outline mixed angina.

A
  • unpredictable, develops at different levels of exercise
  • common
  • probs due to stenosis&vasospasm
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12
Q

Outline vasospastic (Prinzmetal’s) angina.

A
  • decreased oxygen supply
  • due to spasm of coronary artery- tight enough constriction to cause ischemia
  • can occur at rest
  • often at night
  • Transmural ischemia cos all layers of the heart wall are affected due to the tightness of the constriction
  • Patients may/may not have atherosclerosis with it
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13
Q

Outline micro vascular(syndrome X) angina

A

-Chest pain
-Normal coronary angiogram
-Positive exercise test
-Endothelial dysfunction
-Constricted microvasculature
-Occurs more commonly in women.
with signs associated with decreased blood flow to heart tissue but with normal coronary arteries.
-Coronary arteries are normal

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14
Q

Outline unstable angina

A
  • decreased oxygen supply
  • due to transient formation of a non-occlusive thrombus
  • an acute coronary syndrome
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15
Q

What can we use for immediate relief/short term prevention of angina?

A

-Short acting nitrate

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16
Q

What can we use for ongoing prophylaxis of angina?

A
  • Beta blockers
  • long acting nitrate
  • ivabradine
  • nicrorandil
  • ranolazine
17
Q

How can we treat angina

A
  • GTN

- rest

18
Q

Outline the use of organic nitrates in angina

A
  • cellular mechanism= NO donor
  • Haemodynamic mechanism: decreased CVP/preload, leads to and increased coronary blood flow
  • GTN taken sublingually= v rapid &used for cutting short an angina attack of preventing an anticipated attack
  • Other organic nitrates are longer acting and are taken on an ongoing basis( pills,ointments,patches)
19
Q

How is the effectiveness of longer acting nitrates limited? How can this be avoided?

A
  • development of TOLERANCE

- Can be avoided by a daily 8 hour drug free period (typically at night)

20
Q

Outline the haemodynamic effects of nitrates.

A

Major actions:
-relax venules & veins, so decrease CVP and thus decreases cardiac wall tension so decreases cardiac demand
Minor actions:
-Dilate larger coronary arteries, increasing blood flow through coronary collaterals
-decrease TPR and afterload, therefore decreasing oxygen demand
Side effects:headache, facial flushing, decreased BP, reflex increase HR

21
Q

What is the aim of drug treatments for angina?

A
  • Limit the number, severity& sequellae of anginal attacks, thereby improving QOL
  • main mechanism is to decrease cardiac oxygen demand
  • secondary mechanism= increase the o2 supply to the ischaemic zone by decreasing the HR and increasing the blood flow in coronary arteries
  • protect against the future
22
Q

What is Ivabradine used for?

A
  • Decreases heart rate because it inhibits the funny current
  • Decreases force of contraction
  • Increases perfusion
23
Q

What is Ranolazine used for

A
  • Anti-anginal medication
  • Decreases wall tension
  • By blocking late inward sodium currents, calcium overload and diastolic wall stress are reduced, leading to improved coronary blood flow.
  • prevents arrythmias
24
Q

Which drugs can be used to treat angina?

A

-Ivadbradine
-Beta blockers
-Ranolazine
-Nitrates
(Calcium channel blockers-e.g amylodipine and potassium-ATP channel activators-e.g nicorandil also)

25
Q

How is GTN metabolised?

A
  • GTN is converted to superoxide,NO and oxygen, using mitochondrial aldehyde dehydrogenase 2 enzyme
  • NO and oxygen allow for vasodilation due to guanylate cyclase
26
Q

What is the function of Nicorandil?

A

-K-ATP channel activator
-Has dual action…
1.)Opens ATP-sensitive K+ channels in vascular SMCs
2.)Stimulates guanylate cyclase, so increases vascular SMC
These effects lead to relaxation of vascular smooth muscle and therefore venous& arterial vasodilation

27
Q

What would be the effect of an increased late sodium current?

A
  • Action potential prolongation
  • leads to afterdepolarisations
  • could cause arrythmias
28
Q

What are the different methods of revascularisation?

A
  • Percutanous coronary intervention (PCI): A balloon is inflated to reopen a coronary artery that has undergone stenosis
  • Coronary artery bypass grafting (CABG): uses pieces of saphenous vein or diverted internal mammary artery
29
Q

What is the issue with PCI?

A
  • Restenosis may occur and symptoms may return

- May be resolved with the use of stents

30
Q

Compare and contrast PCI & CABG

A
  • CABG is preferred in patients with more serious/advanced coronary artery disease
  • CABG is much more invasive than PCI
  • Much more invasive than PCI as the chest must be opened& the patient is usually on cardiopulmonary bypass
  • Unlike PCI, CABG improves survival
31
Q

Most of the drugs used to treat angina act by reducing one or more of the 4 factors which determine cardiac output and therefore work; what are these factors?

A
  1. ) Preload
  2. ) Afterload
  3. ) HR
  4. ) Cardiac contractility
32
Q

What is syndrome X

A
  • Cluster of abnormalities caused by a high intake of refined carbohydrates,
  • leads to hypoglycemia, hyperinsulinemia, and glucose intolerance followed by diminished insulin sensitivity, further leading to hypertension, hypercholesterolemia, obesity, and T2DM.
33
Q

What is the difference between unstable angina and MI

A

Unstable angina= heart tissue is alive but ischemic ( cos its usually caused by when an atherosclerotic plaque has ruptured, together with thrombosis. The occlusion may not block the whole vessel)

-MI= necrosis has begun in the heart tissue

34
Q

Why should unstable angina be treated as an emergency

A

cos patients are at high risk of progressing to MI

35
Q

What are coronary artery vasospasms?

A
  • occurs in vasospastic/ Prinzmetal’s angina

- The smooth muscles around the arteries constrict extremely tightly- enough to cause ischemia

36
Q

How does angina differ from MI

A
37
Q

Explain the ECG differences between stable, unstable and Prinzmetal’s angina

A
  • Both stable and unstable angina show an ST depression cos the ischemia is sub endocardial
  • Prinzmetal’s shows a ST elevation because the ischemia reaches all layers i.e it is transmural
38
Q

Outline the difference in presentation at rest in stable, unstable & Prinzmetal’s angina

A
  • rest tends to relieve symptoms of stable angina
  • All 3 can be treated by nitroglycerin or GTN ( the dilute form of nitroglycerin) which is a vasodilator
  • Vasoplastic angina also responds to calcium channel blockers (NOT beta blockers)
39
Q

What is responsible for ST depression

A
  • myocardial ischaemia caused by coronary insufficiency

- Subendocardial ischaemia/infarction

Supporting life block (28 decks)

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