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Core Conditions - Cardiovascular > Angina > Flashcards

Angina Flashcards

1
Q

What type of cardiovascular disease is angina pectoralis?

What is the underlying pathology involved?

A
  • It is a form of atherosclerotic cardiovascular disease
  • This involves the build up of fatty plaques on arterial walls
  • Stable angina is a common presentation of coronary heart disease, which develops when the coronary arteries cannot supply enough oxygen-rich blood to the heart (due to atherosclerosis)
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2
Q

When is chest pain present in stable angina?

A
  • chest pain is present on exertion / exercise
  • it is relieved by rest or nitrates
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3
Q

Why is angina referred to as a clinical syndrome rather than a disease?

Why does this occur?

A
  • it represents a clinical manifestation of underlying coronary artery disease
  • it occurs when there is insufficient oxygen supply to the heart to meet demand
    • i.e. there is myocardial ischaemia without infarct
  • the inability to supply the heart occurs as a result of narrowing of the coronary arteries
    • ​this can be due to atherosclerosis or arterial spasm
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4
Q

What is the difference between stable angina and unstable angina?

Why is it important to distinguish these from each other?

A
  • unstable angina is a form of acute coronary syndrome (ACS) where there is an acute narrowing or complete occlusion of the coronary artery due to a blood clot
  • ACS results in infarction of the myocardial tissue, and not just ischaemia
  • the presenting chest pain can feel identical but the treatments are very different
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5
Q

What is the typical pattern of chest pain that angina presents with?

A
  • chest pain is typically central or left-sided
  • there may be radiation to the neck, arm or jaw
  • it is described as a “tight” or “crushing” sensation
  • chest pain is transient and brought on by exertion, but can also be triggered by emotion
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6
Q

What are the risk factors for stable angina?

A

The risk factors are the same as for all manifestations of cardiovascular disease:

  • hypertension
  • dyslipidaemia (abnormal level of lipids in the blood)
    • high LDL and low HDL level
  • diabetes
  • obesity
  • family history of arterial disease
    • ​this is significant when a first degree relative has had an MI before the age of 55
  • smoking
  • advancing age
  • male gender
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7
Q

Other than chest pain, what other symptoms may angina present with?

How long do symptoms usually last for?

A
  • dyspnoea may or may not be present alongside chest pain
  • symptoms typically last for several minutes and are relieved by rest
    • shorter acting symptoms are unlikely to be related to ischaemia
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8
Q

How frequently do patients tend to get angina-like symptoms?

A
  • patients may get frequent symptoms (several times daily)
  • or they may rarely get symptoms (months between episodes)
  • this does not necessarily correspond to the severity of the disease
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9
Q

What is crescendo angina?

What risk is associated with this and why is it important to monitor changes in patient’s angina symptoms?

A
  • crescendo angina occurs when attacks are increasing in frequency and / or severity
  • it is correlated with a high risk of ACS
  • any changes to a patient’s usual pattern of symptoms should be considered a significant risk for ACS and investigated as such
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10
Q

How is angina differentiated from ACS?

What factor in the history will increase suspicion of ACS?

A
  • it should be treated as ACS when the pain does not resolve within 5 minutes of cessation of activity** and/or with the use of **GTN spray
  • angina is typically exertional
  • suspicion of ACS is increased if symptoms have occurred at rest
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11
Q

What is the difference in the way that MI and angina damage the heart muscle?

How should any diagnosis of sudden onset chest pain be treated?

A
  • MI causes permanent damage to the heart muscle (infarction)
  • stable angina causes ischaemia, but not infarction (no permanent damage)
  • they present with very similar symptoms so any sudden onset chest pain should be treated as ACS until proven otherwise
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12
Q

What are the 3 possible underlying causes for angina-like symptoms?

A
  • atheroma seen in coronary artery disease
    • this accounts for the vast majority of cases
  • aortic valve disease
  • hypertrophic cardiomyopathy
    • ​involves thickening of the myocardium, which makes the heart muscle stiff and less effective at pumping blood
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13
Q

Other than exertion, what are some other precipitating factors for angina?

A
  • cold weather
  • heavy meals
  • intense emotion
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14
Q

What is silent ischaemia?

A
  • this is myocardial ischaemia that presents as shortness of breath or without symptoms
  • it can sometimes be confused for angina
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15
Q

What are the different modalities involved in diagnosing stable angina?

A
  • It is diagnosed with a combination of history, ECG and myocardial imaging (typically an angiogram)
  • need to rule out other causes of chest pain - particularly ACS
  • the history should be “typical” of angina, with an ECG
  • diagnosis is then confirmed with imaging
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16
Q

What changes might be present on an ECG for stable angina?

A
  • the ECG can be normal, but changes can include:
    • pathological Q waves
    • ST depression
    • LBBB
    • T-wave flattening or inversion
17
Q

What is the first line imaging investigation for stable angina?

A

CT coronary angiogram

  • this is performed to confirm the diagnosis
  • if there is very high clinical suspicion, you can refer to cardiology without imaging and start treatment first
18
Q

What are the key factors that a patient will mention in a typical history of stable angina?

A
  • chest pain that is “tight”, “heavy” or “gripping”
    • it is typically felt behind the sternum
    • can radiate to the neck, jaws, arms and sometimes back
  • shortness of breath
  • BOTH pain and SOB are brought on by exertion and relieved by rest
  • symptoms typically last several minutes after the precipitating event has stopped
  • classically relieved by GTN
19
Q

What main risk factors increase the likelihood of a diagnosis of angina?

A
  • smoking
  • hypertension
  • diabetes
  • FHx of cardiovascular disease < 55
  • raised cholesterol
20
Q

When should an ECG be performed in someone with angina and why?

A
  • the ECG will often be normal

a normal ECG does not exclude diagnosis of angina or ACS

  • if performed during an episode of angina (e.g. during an exercise tolerance test) then changes might be seen:
    • ST depression
    • ventricular ectopic beats
    • bundle branch abnormalities - mainly LBBB
21
Q

Why might a CXR be performed in suspected angina?

A
  • used to look for other causes of chest pain
    • e.g. pneumonia, pneumothorax
  • may show signs of heart failure, which is associated with severe coronary artery disease
22
Q

Why might an exercise tolerance test be performed?

Can it be used to diagnose stable angina?

A
  • can be used to assess for symptoms and ECG changes when the heart is stressed
  • exercise increases the cardiac load and can provoke myocardial ischaemia
    • this manifests as chest pain, dyspnoea and ECG changes
  • ECG based ETT cannot diagnose stable angina, but it can be used to rule out coronary artery disease after a single acute episode of chest pain
23
Q

What is involved in a CT coronary angiogram?

Why is this recommended as the primary diagnostic investigation?

A
  • contrast is injected through a peripheral cannula
  • scan is conducted while the patient holds their breath and takes about 10 - 15 seconds
  • contrast fills the coronary arteries and can indicate where they are narrowed
  • this is a non-invasive test
24
Q

What is a myocardial perfusion scan (MPS)?

What is the main drawback of this test?

A
  • it is a type of stress test that shows blood flow to different areas of the heart during exercise
  • reduced blood flow to any given area can indicate vessel blockage in the vessel associated with that particular area of the heart
  • it is an alternative to CTCA by does NOT directly visualise the arteries
25
Q

Why is an angiogram not used to diagnose angina despite being the most accurate diagnostic test?

How does this work?

A
  • it is expensive and carries risk
  • it is invasive and involves inserting a cardiac catheter
  • it gives exact information on the level of narrowing of the coronary arteries and which vessels are affected
26
Q

When is coronary artery narrowing considered significant?

A
  • when the luminal diameter is reduced by >70%
  • proximal narrowing of the left main coronary artery and left anterior descending artery is associated with a poor prognosis
  • angiogram can be used to assess the extent of coronary artery lesions when revascularisation therapies are being considered
27
Q

What are the 4 different stages in the Canadian Cardiovascular Society Angina Classification?

A

Class I:

  • ordinary activity (e.g. walking / climbing stairs) does not precipitate angina

Class II:

  • angina is precipitated by walking upstairs, cold weather or meals

Class III:

  • marked limitation of normal physical activity

Class IV:

  • symptoms present at rest
  • unable to carry out many normal physical activities
28
Q

Once the presence of stable angina is confirmed, what is the next step involved in risk stratification?

A
  • the presence of angina indicates underlying coronary artery disease
  • the severity of this underlying cardiac disease needs to be evaluated to assess future risk of MI and whether or not revascularisation is indicated
  • this involves coronary artery stenting or coronary artery bypass graft (CABG)
29
Q

What are the prognostic indicators for determining whether revascularisation is indicated?

A
  • left ventricular function
  • stress testing
  • coronary artery disease extent as seen on angiogram
  • age
  • diabetes
  • hypertension
  • hypercholesterolaemia
  • heart failure
30
Q

What is the annual mortality for angina?

What risk factors greatly increase annual mortality?

A
  • stable angina (without history of MI and with normal resting ECG and normal BP) has an annual mortality of 1.5%
  • presence of an abnormal ECG - 8.4%
  • hypertension - 7.5%
  • both - 12%
  • T2DM doubles the above risks
31
Q

What are the 2 main mechanisms used to relieve the symptoms of angina?

A
  • increasing blood flow to the heart muscle by dilating coronary arteries with glyceryltrinitrate (GTN) spray
  • decreasing the workload on the heart
    • e.g. with a beta-blocker or calcium channel blocker
32
Q

What are the 4 medications considered to be the first-line treatment for stable angina?

A
  • beta-blocker
  • calcium channel blocker
    • reserved for patients who are unable to tolerate beta-blockers or whose symptoms are incompletely controlled with beta-blockers
  • nitrates
    • ​to provide quick relief during acute episodes
  • aspirin (or other anti-platelet drug)
33
Q

What are examples of beta-blockers that might be prescribed?

How do they work?

A
  • e.g. atenolol or metoprolol
  • they decrease heart rate, contractility and cardiac output, which reduces cardiac O2 demand
  • proven to reduce MI and sudden death risk
34
Q

What are examples of calcium channel blockers?

A

verapamil or diltiazem

35
Q

How do nitrates work?

What is typically prescribed and what warning should be given to the patient?

A
  • GTN sublingual spray / tablets should be carried at all times to relieve acute episodes
  • they work by causing vasodilation
  • they provide quick relief (within a few minutes) that lasts for up to 30 minutes
  • they can cause hypotension
36
Q

What other anti-platelet drugs might be prescribed?

Why are these prescribed?

A

clopidogrel or ticagrelor

these reduce the risk of thrombus formation and thus ACS

37
Q

What is involved in the second-line treatment for stable angina?

A
  • consider adding a long-acting nitrate
  • e.g. isosorbide mononitrate
  • the effects of this typically last 4 - 6 hours
38
Q

What is involved in third-line treatment of stable angina?

A

PCI - cardiac stent / balloon angioplasty:

  • these procedures are performed simultaneously to reduce symptoms of stable angina
  • no evidence that this improves survival or reduces risk of ACS

Coronary artery bypass graft (CABG):

  • completely eliminates symptoms in most patients
  • modest improvement in survival for those with left main coronary artery disease or triple vessel disease (but not class I or II)
  • better outcomes in diabetics than PCI

Core Conditions - Cardiovascular (6 decks)

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