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CVS pathophysiology > Angina > Flashcards

Angina Flashcards

1
Q

What is angina?

A
  • cardiac chest pain

- discomfort in chest associated with myocardial ischaemia but without myocardial necrosis

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2
Q

Describe the mechanism of angina

A
  • mismatch between supply of O2 and metabolites to myocardium and myocardial demand for them
  • normally due to reduction in coronary BF to the myocardium
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3
Q

Causes of stable angina

A
  • obstructive coronary atheroma
  • coronary artery spasm ( uncommon)
  • coronary inflammation/artertisi(rare)
  • reduced O2 transport ( anaemia) [ uncommon]
  • pathologically increased myocardial O2 demand ( LVH, significant aortic stenosis and hypertrophic cardiomyopathy)
  • Thyrotoxicosis
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4
Q

Most common cause of atheroma

A
  • coronary atheroma
  • On activity? with the increased mycardial O2 demand, obstructed coronary blood flow leads to myocardial isachaemia then symproms of angina
  • myocardial O2 demand increases in situations where HR and BP rise; excercise, anxiety/emotional stress after a big meal
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5
Q

Stable angina

A
  • myocardial isachaemia causing angina pectoris
  • precipitated by excess myocardial O2 demand ( exertion, cold weather, emotional stress, after heavy meal)
  • pain in LHS chest region, and left arm
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6
Q

Site, character, radiation sites of pain - Stable angina

A

site ; retrosternal
character of pain = tight band/pressure/heaviness
radiation sites; neck and/or jaw, down arms

Sometimes on extertion:

  • breathlessness
  • excessive fatigue on exertion for activity taken
  • near syncope(faint) on exertion

More often in the elderly or those with diabetes mellitus: probably due to reduced pain sensation. ?
SHOULDNT BE
-localised pain
-lasting for hours
-sharp stabbing pain ( pleuritic/pericardial)
-assoc with body movements/

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7
Q

Relieving factors of stable angina

A

-rapid improvement with GTN/physical rest

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8
Q

Differential diagnoses for chest pain

A

Cardiovasular causes:
aortic dissection, pericarditis

Respiratory: pmeumonia, pleurisy, peripheral pulomary emboli ( pleuritic)

Muscoskeletal: cervical disease, costochrondritis, muscle spasm, strain

GI causes: gastro-oesophageal reflux, osophageal spasm, peptic ulceration, bilary colic, cholecytitis, pancreatitis

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9
Q

Risk factors for coronary artery disease

A
  • age, gender, creed?, FX, genetic factors
  • Smoking, lifestyle (diet/excercise), diabetes mellitus( glycaemic control reduces CV risk), hypertension (BP control ‘’’’) , hyperlipidaemia ( lowering reduces risk)
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10
Q

Stable angina - Examination

A
  • tar staining of fingers
  • obesity (centripedal ), Xanathalasma and corneal arcus ( hypercholesetrolaemia)
  • hypertension, abdominal aortic aneurysm arterial bruits, absent/reduced peripheral pulses
  • diabetic retinopathy, hypertensive retinopathy on fundocscopy?
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11
Q

Signs of exaceerbating/associated conditions

A
  • pallor of anemia
  • tachycardia, tremor, hyper-reflexia of hyperthyroidism
  • ejection systolic murmur, plateau pulse of aortic stenosis
  • pansystolic murmur of mitral regurgitation
  • signs of HF ( basal crackles, elevated JVP, peripheral oedema)
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12
Q

Investigations for stable angina

A
  • Bloods
  • CXR
  • electrocardiogram
  • excercise tolerance test ( ETT)
  • myocardial perfusion imaging
  • CT coronary angiography

-cardiac catherterisation/cornorary angiography

Invasive angiography if:

  • early/postiive ETT ( suggests multi vessel ds?)
  • angina refractory to medical therapy
  • daignosis not cear after non-invasive tests
  • young cardiac patients work
  • occupation/lifestyl with risk ( dirvers etc)
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13
Q

Investigations of stable angina - Bloods

A
  • FBC
  • lipid profile
  • fasting glucose
  • electrolytes
  • liver and thyroid tests
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14
Q

Investigations of stable angina - CXR

A

may show pulmonary oodema/other causes of pain

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15
Q

Investigations of stable angina :Electrocardiogram

A
  • evidence of prior myocardial infarction ( ie pathological Q-waves)
  • evidence of left ventricular hypertrophy ( ie high voltages, lateral ST-segment depression/ ‘‘strain pattern’’
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16
Q

Investigations of stable angina - excercise tolerance test

A
  • walking to produce sufficient CV stress

- if negative at high workload, prognosis is good

17
Q

Investigations of stable angina - myocardial perfusion imaging

A
  • can detect CAD, localise isachaemia + assess size of area affected
  • requires radioactivity
  • either excercise or pharmacological stress: adenosine, dipyridamole, dobutamine
18
Q

Investigations of stable angina - cardiac catheterisation/coronary angiography

A
  • shows, sites, distribution and nature of atheromatous disease
  • allows decision on what treatment is best
  • whether medication alone/percutaneous coronary intervention and stengting or coronary artery bypass graft surgery
  • done under local anaesthetic
  • arterial cannula inserted into femoral/radial artery
  • coronary catherters passed to aortic root + itnroduced into ostrium of coronary arteries
  • radio-opaque contrast injected down coronary arteries and visualised on x-ray
19
Q

What is an invasive coronary angiography?

A

a 2D ‘lumenogram’’ as iodinated contrast/dye is passed through arteries

20
Q

Atheroma in an invasive coronary angiography

A

views in different planes as atheroma is eccentric in natture
-?? shows stenosis in mid right coronary artery, amendable to angioplasty

21
Q

Treatment strategies for treatment for stable angina

A

General
-address risk factors ( BP,c holesterol, DM, lifestyle)

Medical treatment

Revascularisation ( if symptoms not controlled)
-percutaneous coronary intervention + coronary artery bypass grafting

22
Q

Treatment of stable angina

A

Influencing disease progression:

  • Statins
  • ACE inhibitors
  • aspirin

For relief of symptoms:

  • Beta blockers
  • Ca2+ channel blockers
  • Ik channel blockers
  • Nitrates
  • K+ channel blockers
23
Q

Treatment of stable angina- Statins

A
  • consider if total cholesterol > 3.5mmol/L

- Reduces LDL-cholesterol depositiation in atheroa and stabilises atheroma reducing plaque rupture and ACS?

24
Q

Treatment of stable angina- ACE inhibitors

A
  • if increased CV risk + atheroma

- stabilises endothelium + reduces plaque rupture

25
Q

Treatment of stable angina: Apsirin

A
  • 75mg/clopidogrel if intolerant to aspirin

- may not directly affect plaque but protects endothelium + prevents platelet activation/aggregation

26
Q

Treatment of stable angina - beta blockers

A
  • achieve resting HR < 60bpm

- reduced myocardial work + antiarrythmic effects

27
Q

Treatment of stable angina - Ca2+ channel blockers

A
  • achieve resting HR < 60bpm
  • central acting ( diltiazem/verapamil if Beta blockers C-I
  • produce vasodilation; peripherally acting dihydropyridines ( amlogipine, feldodipine)
28
Q

Treatment of stable angina- Ik channel blockers

A
  • achieve resting HR < 60bpm

- ivabridine reduces sinus node rate

29
Q

Treatment of stable angina - K+ channel blockers

A
  • nicorandil

- nitrate molecule + K+ channel helpful in preconditioning?

30
Q

Treatment of stable angina - percutaneous coronary intervention

A
  • similar beginnings to coronary angiography but cross stenotic lesion with guidewire and squash athermoatous plaque into walls with ballone and stent
  • if stent used, aspirin and clopidogrel taken together whilst endothelium covers stent struts and is no longer seen as a foreign body with associated risk of thrombosis
31
Q

Risks of PCI

A

-RETONOSIS

32
Q

Risks of PCI

A

-Retonosis

33
Q

Treatment of stable angina - coronary artery bypass surgery

A
  • in diffuse multi vessel CABG best option for stable angina

- patients must continue disease modifying medication and predicatble detiorartion in vein grafts after 10yrs

CVS pathophysiology (23 decks)

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