Angina Flashcards
What is angina pectoris?
Angina is discomfort in the chest and/or adjacent areas (jaw, shoulder, back, arm) caused by myocardial ischaemia.
This is most common,y due to CAD, but there are other causes
Who is the typical patient presenting with angina?
Middle-aged man, elderly man or woman with a FH of cardiovascular heart disease and 1 or more of these risk factors ( smoking, HTN, hypercholesterolaemia, diabetes)
What are the symptoms of Angina?
Exertional chest pain, dyspnoea.
Pain often describes as heaviness or tightness.
Pain may radiate into arms, neck or jaw.
Diagnosis of angina
History and examination is the most important then ECG and blood tests
Blood tests to detect conditions exacerbating angina such as anaemia and thyrotoxicosis
ECG is often normal
Stress ECG is exertional ST depression isn’t diagnostic however.
the new CADSCOR system before CT but after first clinical evaluation
64 slice CT Coronary angiography is first-line to confirm stable angina: confirms occlusion of vessels
Blood sugar and lipids to rule out diabetes and dyslipidaemia
What are the causes of angina?
Impaired oxygen supply to myocardium: CAD (atherosclerosis, diabetes, arteritis) Coronary artery spasm Severe anaemia or hypoxia Congenital CAD Increased myocardial oxygen demand: LV hypertrophy (HTN, aortic valve disease) Tachyarrhythmias
What is typical angina?
Three characteristics:
1) Deep poorly localised pressure, squeezing or burning sensation and is usually relieved by rest
2) Caused by physical activity, emotional excitement or psychological stress
3) Relieved by rest or GTN within about 5 minutes
What is atypical (unstable) angina?
Meets 2 of the typical angina characteristics
- Increasingly frequent, prolonged (>20 min), or severe angina or chest discomfort that is described as frack pain
- precipitated by progressively lower levels of physical activity or even at rest
- usually caused by disruption of a plaque with partial thrombosis.
Acute MI may be imminent
What is prinzmetal variant angina?
Caused by coronary artery spasm.
Uncommon form
Anginal attacks unrelated to physical activity
Responds promptly to vasodilators- don’t give beta blockers
Coronary artery spasm is caused by narrowing of arteries through contractions.
What is microvascular angina?
Signs of ischaemia but with normal coronary arteries.
Diagnosis of exclusion i.e rule out all other possible causes first
Can be more severe and longer-lasting
What are the most important risk factors for developing CAD?
Age Gender Diabetes HTN Smoking Hyperlipidaemia
Management of Angina
ACUTE: Sublingual glyceryl trinitrate- 0.3-0.6mg every 5 minutes PRN, maximum of 3 doses
Lifestyle Education- Weight management, increased physical activity, dietary modifications, lipid goals and smoking cessation.
Antiplatelet therapy- Aspirin 75mg OD if CI then Clopidogrel 75 mg OD
IF anginal attacks are frequent THEN
Anti-anginal therapy:
Beta-blocker is the first-line treatment: metoprolol (50mg OD), propranolol (20mg OD), bisoprolol (5mg OD) NOT atenolol or other beta-blocker with intrinsic sympathomimetic activity
Second-line therapy is a calcium-channel blocker as an alternative or additional therapy to beta-blockers-nifedipine (30 mg OD), amlodipine, felodipine (both 5 mg OD) NOT verapamil
Long-acting nitrates can be used as additional therapy or in patients with CI to the first two treatments- isosorbide mononitrate (20mg)
Statins: atorvastatin (10-20mg OD) moderate intensity (40-80mg OD) high intensity. Most patients should receive high-intensity statin treatment.
Antihypertensive therapy- beta-blockers AND ACE inhibitors or ARB
Blood sugar control in patients with diabetes.
Revascularisation- a Bypass graft or PCI is recommended in continued unacceptable angina despite maximal medical therapy AND in people with left mainstem artery stenosis or triple vessel disease.
Treatment of any exacerbating factors for angina- anaemia, arrhythmias and thyrotoxicosis.
Differentials of Angina
GORD Anxiety disorders Pulmonary embolism Musculoskeletal pain Pneumothorax Pericarditis Pneumonia with pleurisy
Complications of Angina
MI
Stroke
Depression
Chronic heart failure
What other parts of clinical history are relevant to diagnosing coronary artery disease?
Con-current diagnosis of coronary artery disease (e.g. stable angina, previous myocardial infarction).
Con-current diagnosis of other atherosclerotic arterial diseases – (e.g. ischaemic stroke, peripheral vascular disease, renovascular disease).
Family history of coronary artery disease or atherosclerotic arterial disease.
