angina Flashcards
epidemiology
increases with age in both sexes
risk factors (7)
hypertension, hyperlipidaemia, diabetes mellitus, sedentary lifestyle, obesity, smoking, Fx
diagnosis : typical, atypical and non-angina
characterised by chest pain ! heavy, tight, gripping pain centrally or retrosternally and may radiate to jaw / arms / neck / teeth / back (atypical angina is 2/3 of these things and non-angina chest pain is 1/3)
visceral pain from myocardial hypoxia - will be difficult for patients to describe, often give gestures to where the pain is
what kind of pattern is the pain?
sometimes patients will deny it even as a pain but as a dull ache ..
can be worsened by cold wind ! and also after eating
only comes on for a few minutes
**
must remember to ask what exacerbates it/alleviates it
does it come on for a long time? (usually not angina if it comes on for a long time but more likely to be an MI!!)
diagnosis : stable angina (classed)
class 1 - angina with strenuous activity only class 2 -angina during ordinary activity ie walking up a hill, with mild limitations of activity class 3 - angina on low levels of activity ie walking 50-100m with marked restrictions on activity class 4 - angina at rest or with any type of exercise
what is revascularisation ?
restored perfusion of a previously ischaemic body part/organ …think stenting !
diagnosis : unstable angina
angina of recent onset or sudden deterioration of stable angina, symptoms occurring frequently at rest
diagnosis : refractory
patients with severe coronary artery disease
revascularisation is not possible and cannot be managed with medical therapy
diagnosis : vasospastic/variant
angina that comes without provocation, usually at rest as a result of a coronary artery spasm (happens more frequently in women)
diagnosis : microvascular
exercised induced angina, but have non-obstructed coronary arteries (intracoronary acetylcholine may cause coronary spasm)
good prognosis - very difficult to treat
examination
- look for signs of anaemia, hyperlipidaemia, thyrotoxicosis
- need to rule out aortic stenosis (narrowing of exit of LV)
- hypertension should be identified if existing (BP)
- BMI and waist circumference
what is thyrotoxicosis ?
excess thyroid hormone action at tissue level due to high levels of thyroid hormone concentrations in blood - can case hyperthyroidism
initial investigations for suspected angina
full blood count thyroid function tests fasting glucose HbA1c (diabetes m) fasting lipid profile glomerular filtration rate troponin (unstable angina) --- ECG Echocardiogram ambulatory ecg CXR
investigations for typical/atypical/non-angina with ST changes or Q waves and also if have known CAD
CTCA (computed tomography coronary angiography)
inv. for stable angina
via clinical assessment and/or CTCA,SPECT,stress echocardiogram, stress MRI
spect = single photon emission ct
management of stable angina (1)
> patients should be informed that their prognosis is good ! (mortality = <2%)
lifestyle management should be instigated (prevention of CAD)
given short-acting nitrates for sudden onset (vasodilators)
secondary prevention
management of stable angina (2)
> prescribe beta blockers OR calcium channel blockers
>if not tolerated or contraindicated, then prescribe long acting nitrates ie ivabradine, nicorandil, ranolazine
>if still symptomatic then prescribe both beta blockers and calcium channel blockers or switch from beta to calcium
»if still symptomatic on both then consider revascularisation (coronary artery bypass grafting/percutaneous coronary intervention)
percutaneous coronary intervention - PCI
the process of dilating a coronary artery stenosis by introducing a inflatable balloon and a metallic stent into arterial circulation via femoral/brachial/radial artery
>bare metal stents have a higher incidence of restenosis compared to drug eluting stents
-may need emergency CABG
-MI may occur and stroke and heart failure are also a risk the same goes for CABG
-renal failure
-infection
>need anti-lately drugs and anticoagulants as well
>catheter to ostium of artery
coronary artery bypass grafting - CABG
when autologous veins OR arteries are anastomosed (joined together) to the ascending aorta and to native coronary arteries distal to the area of stenosis
big surgery !!
-MI is a real possibility (3%)
-infection
pharmacological therapy in stable angina !! (PTSA!!) - vasodilators (1)
short-acting !
glyceryl trinitrate: >0.3-1.0mg sublingual and 2.0-3.0 buccal
>prophylaxis and treatment of angina (rapid onset)
>repeat after 5m if symptomatic
>can cause headache and flushing
isosorbide mononitrate: >10-60mg twice daily (2d)
>prophylaxis
>can cause headache and flushing
>contraindicated with phosphodiesterase type 5 inhibitors
PTSA!! - vasodilators ivabradine
long-acting !
ivabradine : 2.5-7.5mg 2d
>inhibits pacemaker funny current in SA node
>use in sinus rhythm
>can cause bradycardia and phosphenes
>contraindicated with sick sinus syndrome, AV block
PTSA!! - vasodilators nicorandil
5-30mg 2d
activates ATP sensitive potassium channels and has nitrate properties
can cause headache, flushing, oral ulceration
PTSA!! - vasodilators ranolazine
375-750mg 2d
inhibits late sodium channels into cardiac cells
can cause dizziness, constipation, lengthened QT
PTSA!! - beta blocker bisoprolol
2.5-10mg 2d
inhibits Badrenoceptors, reduces HR and BP and myocardial oxygen consumption
!! caution !! with COPD, acute heart failure, AV conduction
can cause, fatigue, peripheral vasoconstriction, sexual dysfunction, bronchospasm
PTSA!! calcium channel blocker verapamil
phenylalkylamine
80-120mg 3d
inhibit calcium channels in myocardium, cardiac conductive tissue and vascular smooth muscle
can cause constipation
PTSA!! calcium channel blocker diltiazem/verapamil/amlodipine
benzothiapines
60-120mg 3d
both diltiazem and verapamil are contraindicated in severe bradycardia, LV failure w pul. congestion and AV block
amlodipine - dihydropyridines
5-10mg 1d
can cause ankle oedema and tachycardia
PTSA!! event reducing anti platelet
aspirin - 75-100mg 1d
clopidogrel - 75mg 1d
PTSA!! event reducing ACE inhibitor or ARB
enalapril 10mg 1d
for hypertension heart failure chronic kidney disease
**
ACE = angiotensin converting enzyme
ARB = angiotensin receptor blocker
PTSA!! event reducing statins
atorvastatin - 80mg 1d
reduced LDL cholesterol to <1.8mmol/L
differential diagnosis of chest pain
GI tract: - can often be typical -
acid reflux, provoked by food -
peptic ulcer pain -
oesophageal spasm -
biliary colic
Musculoskeletal pain:
injury
nerve root pain
Pericarditis: often relieved by posture
Pleuritic pain: exacerbated by breathing, focal
MI: sweating, nausea/vomit, angor animi ! severe !
ongoing pain despite being on more than 10mg of morphine
PE: dull, breathlessness (perhaps pleuritic)
Dissection of the aorta: excruciating pain, severe then eases - tearing of the aortic wall, haemorrhage etc
relation to CAD
if you have angina then that is a clinical diagnosis of CAD
can get CAD without angina but not angina without CAD
