Angina Flashcards

Question

Treatment regimen

Answer 1

Beta blockers first Then CCBs Then something else eg aspirin, ivabradine, statin All patients with stable angina due to atherosclerotic disease should have long term aspirin and statin

Answer 2

Aspirin 75mg daily Ace inhibitors if diabetes Statin Treat high BP

Answer 3

By far most commonly due to a reduction in coronary blood flow to the myocardium, caused by: Obstructive coronary atheroma (Very common) Coronary artery spasm (Uncommon); Coronary inflammation/arteritis (Very rare) Uncommonly due to reduced O2 transport: Anaemia of any cause Uncommonly due to pathologically increased myocardial O2 demand: Left ventricular hypertrophy (LVH); as seen in significant persistent hypertension, significant aortic stenosis and hypertrophic cardiomyopathy. Thyrotoxicosis

Answer 4

Essential to establish the characteristics of patients pain to differentiate from other causes of chest pain: Site of pain (watch for patient gestures): retrosternal Character of pain: often tight band/pressure/heaviness. Radiation sites: neck and/or into jaw, down arms. Aggravating e.g. with exertion, emotional stress & relieving factors e.g. rapid improvement with GTN or physical rest. Very occasionally myocardial ischaemia occurs with no chest pain but other symptoms on exertion: Breathlessness on exertion Excessive fatigue on exertion for activity undertaken Near syncope on exertion. More often in the elderly or those with diabetes mellitus: probably due to reduced pain sensation.

Answer 5

Sharp/‘stabbing’ pain; pleuritic or pericardial. Associated with body movements or respiration. Very localised; pinpoint site. Superficial with/or without tenderness. No pattern to pain, particularly if often occuring at rest. Begins some time after exercise. Lasting for hours.

Answer 6

Cardiovascular causes: Aortic dissection (intra-scapular “tearing”), pericarditis Respiratory: Pneumonia, pleurisy, peripheral pulmonary emboli (pleuritic) Musculoskeletal: Cervical disease, costochondritis, muscle spasm or strain GI causes: Gastro-oesphageal reflux, oesophageal spasm, peptic ulceration, biliary colic, cholecystitis, pancreatitis

Answer 7

I Ordinary physical activity does not cause angina, symptoms only on significant exertion. II Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs. III Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs. IV Symptoms on any activity, getting washed/dressed causes symptoms.

Answer 8

Non-modifiable Age, gender, creed, family history & genetic factors. Modifiable Smoking Lifestyle- exercise & diet Diabetes mellitus (glycaemic control reduces CV risk) Hypertension (BP control reduces CV risk) Hyperlipidaemia (lowering reduces CV risk)

Answer 9

Tar stains on fingers Obesity (centripedal) Xanthalasma and corneal arcus (hypercholesterolaemia) Hypertension, Abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses. Diabetic retinopathy, hypertensive retinopathy on fundoscopy. Signs of exacerbating or associated conditions: Pallor of anaemia Tachycardia, tremor, hyper-reflexia of hyperthyroidism Ejection systolic murmur, plateau pulse of aortic stenosis Pansystolic murmur of mitral regurgitation, and Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema.

Answer 10

``` Bloods CXR ECG ETT Myocardial perfusion imaging Computed tomography (CT) coronary angiography CT coronary angiography Invasive angiography Cardiac catheterisation/coronary angiography ```

Answer 11

Full blood count, lipid profile and fasting glucose; Electrolytes, liver & thyroid tests would be routine.

Answer 12

Often helps show other causes of chest pain and can help show pulmonary oedema.

Answer 13

normal in over 50% of cases may be evidence of prior myocardial infarction i.e. pathological Q-waves. may be evidence of left ventricular hypertrophy i.e. high voltages, lateral ST-segment depression or “strain pattern”.

Answer 14

Often can confirm diagnosis of angina. Relies on ability to walk for long enough to produced sufficient CV stress. Typical symptoms and ST-segment depression for positive test. -ve ETT doesn’t exclude significant coronary atheroma but if negative at high workload overall prognosis is good.

Answer 15

Superior to ETT in detection of CAD, localisation of ischaemia and assessing size of area affected. Expensive, involves radioactivity; depending on availability used where ETT not possible/equivocal. Either exercise or pharmacological stress: adenosine, dipyridamole or dobutamine . Radionuclide tracer injected (iv) at peak stress on one occasion, images obtained; and at rest on another. Comparison between stress and rest images. Normal myocardium takes up tracer. Tracer seen at rest but not after stress = ischaemia Tracer seen neither rest, or after stress = infarction

Answer 16

Early or strongly positive ETT (suggests multi-vessel ds). Angina refractory to medical therapy. Diagnosis not clear after non-invasive tests. Young cardiac patients due to work/life effects. Occupation or lifestyle with risk e.g. drivers etc.

Answer 17

Definition of coronary anatomy with sites, distribution and nature of atheromatous disease enables decision over what treatment options are possible. Whether medication alone or percutaneous coronary intervention (PCI)- most often angioplasty and stenting or coronary artery bypass graft (CABG) surgery. Almost always done under local anaesthetic Arterial cannula inserted into femoral or radial artery. Coronary catheters passed to aortic root and introduced into the ostium of coronary arteries. Radio-opaque contrast injected down coronary arteries and visualised on X-ray. Invasive coronary angiography is 2-D “lumenogram” as iodinated contrast or “dye” is passed through the arteries

Answer 18

General measures Address risk factors: BP, DM, Cholesterol, Lifestyle Medical treatment Drugs to reduce disease progression & symptoms Revascularisation (if symptoms not controlled) Percutaneous coronary intervention (PCI) & coronary artery bypass grafting (CABG)

Answer 19

Statins: consider if total cholesterol >3.5 mmol/l. Reduce LDL-cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS. ACE inhibitors: if increased CV risk and atheroma Stabilise endothelium and also reduce plaque rupture. Aspirin; 75mg or clopidogrel if intolerant of aspirin. May not directly affect plaque but does protect endothelium and reduces of platelet activation/aggregation

Answer 20

ß-blockers; achieve resting hr <60 bpm. Reduced myocardial work and have anti-arrhythmic effects Ca2+ channel blockers; achieve resting hr <60 bpm. Central acting eg diltiazem/verapamil if ß-blockers C-I Ik channel blockers; achieve resting hr <60 bpm. Ivabridine is a new medication which reduces sinus node rate Ca2+ channel blockers; produce vasodilatation Peripherally acting dihydropyridines eg amlodipine, felodipine Nitrates; produce vasodilatation Used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray for immediate use. K+ channel blockers; nicorandil Nitrate molecule and K+ channel helpful in ‘pre-conditioning

Answer 21

Percutaneous transluminal coronary angioplasty (PTCA) and stenting (now in ~95% procedures) Similar beginnings to coronary angiography but cross stenotic lesion with guidewire and squash atheromatous plaque into walls with balloon and stent. If stent used aspirin and clopidogrel taken together whilst endothelium covers the stent struts and it is no longer seen as a foreign body with associated risk of thrombosis. PCI effective for symptoms, but No evidence it improves prognosis in stable disease. Small risk of procedural complication: death=0.1%, MI=0.2%, emergency CABG=0.05% Risk of restenosis: varying from 10-15% with bare metal stents and <10% with drug eluting stents. Also still need to continue disease modifying medication.

Answer 22

In diffuse multi-vessel CABG often best option for stable angina ‘Up front’ risks are significantly > PCI death=1.3%, Q-wave MI=3.9%; these increase in presence of co-morbidity But good lasting benefit- 80% symptom free 5 years later. CABG may confer prognostic benefit in certain subgroups: >70% stenosis of left main stem artery significant proximal three-vessel coronary artery disease two vessel coronary artery disease that includes significant stenosis of proximal left anterior descending coronary artery and who have ejection fraction < 50%. Patients must continue disease modifying medication and predictable deterioration in vein grafts after 10 years.