angina Flashcards
what are the 6 key questions you should ask in chest pain assessment?
how long have you had it? how long does it last? where is it? Localised/generalised/radiation? what's it like? what provokes it/relieves it?
how long should angina pain last?
a few minutes
where is angina pain felt?
localised in the chest wall
what does angina pain feel like?
feels like a constricting chest pain
what provokes and relieves angina pain?
provoked by exertion
relieved by rest
name causes of non-cardiac chest pains?
- Digestive – heartburn, swallowing disorders
- Neurogenic – cervical/thoracic spine, shingles
- Pulmonary – pleurisy, pulmonary fibrosis
- Bony pain – rib fracture, secondary deposits
why is early diagnosis important in non-cardiac chest pain?
because it means;
- fewer unnecessary investigations
- less distress and functional disability
- reduced costs to the hospital
- fewer iatrogenic complications
what are the 2 main causes of angina?
decreased myocardial O2 supply
increased myocardial O2 demand
what are causes of decreased myocardial O2 supply?
o Coronary artery disease; atherosclerosis, spasm, vasculitic disorders, post radiation therapy
o Severe anaemia
what are causes of increased myocardial O2 demand?
o Left ventricular hypertrophy; hypertension, aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy
o Right ventricular hypertrophy; pulmonary hypertension, pulmonary stenosis
o Rapid tachyarrythmias
name methods of diagnosing angina
Clinical assessment, Electrocardiography, LV wall motion analysis, Perfusion imaging
what is the diagnostic challenge with angina?
angina is a manifestation of coronary artery disease so the challenge is to determine whether or not the patient with chest pain has flow limiting coronary obstructions
name non-invasive testing options for angina
functional testing
anatomical testing
what is functional testing used for?
evidence of ischaemia
name methods of functional testing?
ETT, SPEC, stress echo, stress cMR
what is anatomic testing used for?
evidence of obstructive disease
name methods of anatomical testing?
CTCA
what is the most sensitive and specific non-invasive ischaemia test for diagnosing coronary disease?
64 slice CTA
what do NICE guidelines say the first response to a patient presenting with chest pain is?
do a clinical assessment to check for 3 main characteristics
what characteristics are you checking for in clinical assessment for angina?
o Central chest discomfort lasting 5-15 minutes
o Provoked by exertion or emotional stress
o Relieved by rest or nitrates
what is classified as non-anginal pain?
if there is one or less of the typical characteristics in the clinical assessment
what testing do you do for non-anginal pain?
no diagnostic testing
what is classified as atypical angina?
if there are 2 characteristics in the clinical assessment
what is classified as typical angina?
if there are 3 characteristics in the clinical assessment
how is atypical/typical angina diagnosed after clinical assessment?
skip all the different tests and go straight for the CTCA scan
how does increasing coronary flow help reduce the symptoms of angina?
increases O2 delivery
what drugs can be used to increase coronary flow?
nitrates, CaBs, nicrorandil, revasc
in what ways can the oxygen demand on the heart be reduced?
- decreased heart rate
- decreased LV wall tension (decrease BP)
- decreased contractility
- modify energy metabolism
what drugs can be used to decrease heart rate?
beta blockers
ivabridine
what drugs can be used to decrease BP?
BB, nitrates, nicrorandil, CaBs, ranolazine
what drugs can be used to decrease contractility?
BB, CaBs
what drugs can be used to modify energy metabolism?
trimetazidine
what drugs are given in the secondary prevention of angina?
- Aspirin all patients
- Statins all patients
- ACE-I if other indications (HT/DM)
- P2Y12 receptor antagonist all patients after PCI or if intolerant of aspirin
what considerations should be made when looking at the choice for revasc procedure?
- Coronary anatomy
- Patient choice
- Procedural risk: death, stroke, AMI
- Symptomatic benefit
- Repeat revascularisation
- Prognostic benefit
