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Cardiovascular System > Angina > Flashcards

Angina Flashcards

1
Q

What is angina?

A

a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but with no myocardial necrosis

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2
Q

What is the pathophysiology of angina?

A

Mismatch between oxygen supply and metabolites supply to myocardium and the myocardial demand for them

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3
Q

What is angina most commonly due to?

A

-reduction in coronary blood flow to the myocardium commonly caused by an obstructive coronary atheroma

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4
Q

What is angina rarely due to?

A

reduction in coronary blood flow to the myocardium rarely due to Coronary artery spasm (uncommon, Vasospastic angina) or coronary artery inflammation/arteritis (Rare)

or due to Microvascular angina

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5
Q

What is reduced oxygen transport uncommonly due to?

A
  • Anaemia of any cause
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6
Q

What is increased myocardial O2 demand uncommonly due to?

A
  • Thyrotoxicosis

- Left ventricular hypertrophy which is seen in significant hypertension, aortic stenosis, hypertrophic cardiomyopathy

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7
Q

Explain the effect of coronary atheroma on activity.

A
  • Increased myocardial oxygen demand, but atheroma is causing a blockage for the blood to travel through, therefore causing myocardial ischaemia and thus the symptoms
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8
Q

What kinds of activity trigger angina

A
  • emotional distress, anxiety, eating after a huge meal, physical activity, cold weather
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9
Q

How much of the plaque needs to cover the lumen for symptom, and how does atherosclerosis form?

A
  • > 70%
  • Fatty streak -> non obstructive plaque-> obstructive plaque.
  • Atherosclerosis is a progressive process which builds up over icnreasing age.
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10
Q

How does stable angina differ from acute coronary syndrome?

A
  • The plaque is stable but in ACS, there is spontaneous ruptured plaque and local thrombosis, with degrees of occlusion
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11
Q

How to diagnose angina?

A
  • Relived immediately after GTN spray or rest.
  • retrsternal chest pain spreading to arms, neck, jaw
  • “heavy” “tight band” “pressure” pain
  • aggravated by trigger

others:

  • near syncope
  • dyspnoae
  • excessive fatigue
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12
Q

When may it not be angina?

A
  • pleuritic or pericardial chest pain= Sharp, stabbing
  • pain continues after rest
  • associated with body movements or respiration
  • very localised pain
  • no pattern pain
  • lasts for hours and begins some time after exercising.
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13
Q

What are differential diagnoses to angina?

A
  1. cardiovascular
    a) Pericarditis b) Aorta dissection
  2. respiratory
    a) Pleurisy b) Pneumonia c)Peripheral pulmonary emboli
  3. GI
    a) Gastro-oesphageal reflux b) oesophageal spasm c) peptic ulceration d) biliary colic e) cholecystitis.f) pancreatitis
  4. Muscoskeletal
    a) Cervical disease b) costochondritis c)muscle spasm or strain
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14
Q

when the other symptoms (excessive fatigue, near syncope, dyspnoea) more common?

A
  • elderly or diabetes mellitus due to reduced pain sensation
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15
Q

What are risk factors for angina?

A
  • modifiable
    e. g. Lifestyle (Exercise and diet), Diabetes (glycemic control), Hypertension (controlling reduces CV risk), Hyperlipidaemia (same again)
  • non modifiable
    e. g. Genetic factors, age, gender, fam history
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16
Q

What are the signs of angina>

A
  • tar staining
  • xanthalasma and corneal arcus
  • obese
  • hypertension
  • reduced/absent peripheral pulses
  • Diabetic retinopathy, hypertensive retinopathy on fundoscopy.
17
Q

WHAT are signs of exacerbating angina and associated conditions?

A
  • Pallor from anemia
  • Tachycardia
  • tremor
  • mitral regurgitation- Pansystolic murmur
  • aortic stenosis- ejection systolic murmur
  • heart failure- increased JVP, basal crackles, peripheral oedema
18
Q

What are investigations for angina?

A

Blood tests:

a) - lipid profile
b) -FBC
c) -glucose tolerance test
- U&E
- Liver and thyroid test

Myocardial perfusion imaging:

  • superior to ETT
  • localises ischaemia and how much its affected
  • but involves radioactivity

Exercise tolerance test:

  • very good
  • symptoms + ECG AFTER EXERCISE-ST segment depression

CT coronary angiography:

CXR:
- shows pulmonary oedema and other causes of chest pain

ECG:

  • normal in over Half of angina cases
  • evidence of previous MI e.g. pathological Q waves
19
Q

How does myocardial perfusion imaging work?

A
  • needs to happen after exercise or injection of radionuclide tracer at peak stress
  • the tracer is present at rest but disappears after strress- Ischaemia
20
Q

When would you use invasive imaging e.g. coronary angiography

A

Higher risk patients- determines whether medical treatment or angioplasty or CABG is needed. (Revascularisation is needed if symptoms not being controlled by medication.)

21
Q

What is more common procedure for revascularisation?

A

CABG

22
Q

What is the treatment for stable angina?

A
  1. NITRATE gtn spray/ sublingual tablets/patch
    - Long acting nitrates isosorbide mononitrate
  2. ASPIRIN
    - 75 mg
  3. STATINS
    - cholesterol >3.5
    -
  4. ## ACE INHIBITORS
  5. BETA BLOCKER
    - bisoprolol
  6. CA CHANNEL BLOCKER
    if beta blockers CI
    central- Verapamil, diltiazem
    peripheral- amlodipine, femlodopine
  7. Ik CHANNEL BLOCKER
    - Ivabradine
  8. K CHANNEL BLOCKER
    - Nicorandil
23
Q

If medication doesn’t do enough for symptom control what are the next stepS?

A
  • PCI
  • great for symptom control but doesn’t improve prognosis in stable disease
  • CABG
  • long saphenous vein graft
  • better prognosis for- a)70% stenosis left main stem artery and b) significant proximal three vessel CAD c)Two vessel coronary artery disease including the LAD, with EF<50%
  • 80% symptom free for 5 yrs but graft deteriorates
24
Q

What are downsides to botH PCI AND CABG?

A

Need to continue drug medication

25
Q

What do Statins do?

A
  • Reduce LDL-cholesterol deposition in atheroma.

- stabilises the atheroma, reduce the chance of Plaque rupture

26
Q

What do ace inhibitors do?

A
  • Stabilises the endothelium and Reduce the chance of plaque rupture
27
Q

What does aspirin do?

A

Reduces platelet aggregation/ activation, protecting the endothelium.

28
Q

What do beta blockers do?

A

Reduce the myocardial work , antirhytmicc effects.

29
Q

What do ik channel blockers do?

A

-Reduces the Sino atrial rate

Cardiovascular System (10 decks)

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