Angina and ACS Flashcards

1
Q

3 Features of Angina

A
  1. Chest pain radiating to jaw, neck, shoulders or arms
  2. Symptoms brought on by exertion
  3. Symptoms relieved by 5mins rest or GTN spray
    All 3= Typical
    2= Atypical
    0-1= Non-Anginal
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2
Q

Precipitants of angina

A

Emotions, cold weather, heavy meals

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3
Q

Associated symptoms of angina

A

Dyspnoea, nausea, sweatiness, faintness

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4
Q

Features that make angina less likely

A

Pain that is continuous, pleuritic or worse with swallowing.

Pain associated with palpitations, dizziness or tingling

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5
Q

Causes of angina

A

Atheroma

Rarely: anaemia, coronary artery spasm, AS, tachyarrythmias, HCM, arteritis

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6
Q

Types of angina

A

Stable- induced by effort, relieved by rest. Good prognosis
Unstable (crescendo)- Increases in frequency or severity, occurs on minimal exertion or at rest; associated with increased risk of MI
Decubitus angina- precipitated by lying flat
Variant (Prinzmental)- caused by coronary artery spasm

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7
Q

Angina Ix

A

ECG- normal may show ST depression, flat or inverted T waves, signs of past MI
Bloods- FBC, U/E, TFTs, lipids, HbA1c- reasons? see PUK
Consider echo and CXR

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8
Q

ECG in angina

A

Normal does not rule out angina, may show signs of ischaemic changes
Changes on resting ECG consistent with CAD include
-Pathological Q waves
-Left bundle branch block
-St-segment and T wave abnormalities

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9
Q

Angina epidemiology
More common F/M?
Ethnicities?

A

More common in South Asian population
Black Afro-Caribbean people have reduced risk
Higher in lower socio-economic groups

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10
Q

Angina risk factors

A

Increasing age, male gender, CV RF, smoking, diabetes, hypertension, dyslipidaemia, FH of premature CAD, Hx of CAD

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11
Q

Angina Differentials

A

MI- longer than 5mins not relieved by rest
Prinzmetal’s- occurs at rest and exhibits circadian pattern, most episodes occurring early in morning
Acute pericarditis- constant, aggravated by inspiration, lying flat, swallowing and movement
MSK pain- worse on movement
Reflux
Pleuritic
Dissection
Gallstones

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12
Q

If estimated likelihood of CAD greater than 90%?

A

Further investigation unnecessary, manage as angina

Arrange blood tests for conditions that exacerbate angina

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13
Q

Symptoms suggesting ACS

A

Pain at rest (may occur at night)
Pain on minimal exertion
Angina that seems to be progressing repidly
- refer urgently

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14
Q

Ix confirmed CAD in context of angina

A

Treat as stable angina

If suspected that pain is not caused by ischaemia, offer non-invasive functional imaging or refer for exercise testing

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15
Q

If likelihood of CAD between 10-90%?

A

Arrange bloods for conditions that exacerbate angina

Consider aspirin if likely to be stable angina

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16
Q

If estimated likelihood of CAD is 61-90%?

A

Offer invasive coronary angiography

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17
Q

If estimated likelihood of CAD is 30-60%?

A

Offer non-invasive functional imaging for myocardial ischaemia
-MPS, stress echo, first pass contrast enhanced MR perfusion

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18
Q

If estimated likelihood of CAD is 10-29%

A

Offer CT calcium scoring

19
Q

If estimated likelihood of CAD is less than 10%

A

Consider other causes

20
Q

Pharmacological management of angina

A
  • GTN symptom relief
  • Aspirin (clopidogrel if contra)
  • Statins
  • Beta blocker or CCD
  • Then switch or combine
  • If one contra-indicated add a long acting nitrate, ivabradine or ranolazine
  • If both contra-indicated monotherapy with long acting nitrate, ivabradine or ranolazine
  • ACEi if diabetic
21
Q

Coronary revascularisation

A

For those at high risk and those who have failure to be controlled

22
Q

Patients who do not respond to treatment

A
  • Explore patients understanding
  • Establish how symptoms affect quality of life
  • Review diagnosis and consider other causes
  • Explain how the patient can self manage
  • Explain role of psychological factors in pain
23
Q

Angina advice to patient

A

Reduce CV RFs (smoking, diet, physical activity, alcohol)

24
Q

Sexual activity for angina?

A

If patient can climb up and down two flights of stairs briskly without symptoms, sexual activity unlikely to precipitate episode of angina

25
If sexual activity does precipitate angina?
GTN spray immediately before intercourse
26
Contraindication to GTN spray?
Phosphodiesterase inhibitors
27
Complications of angina
- Cardiovascular complications - Anxiety and depression - Reduced general health
28
Prognosis
Annual mortality 1.2-2.4%
29
ACS RF
- NM for atherosclerosis: age, male, FH, premature menopause | - M for atherosclerosis: smoking, DM, hypertension, dyslipidaemia, obesity, inactivity
30
ACS Presentation
- STEMI and NSTEMI may be indistinguishable - Prolonged anginal pain at rest - New onset angina limiting daily activities - Recent destabilisation of angina - Post MI angina
31
ACS chest pain
Associated with sweating, nausea, vomiting, fatigue, SoB, palpitations -Some patients (particularly elderly and diabetics) may not have chest pain
32
Should response to GTN be used to diagnose ACS
No
33
ACS Differentials
- CV: acute pericarditis, myocarditis, aortic stenosis , aortic dissection, PE - Resp: pneumonia, pneumothorax - GI: oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis - MSK
34
ACS Ix
- ECG - Cardiac Enzymes - FBC - Blood glucose (hyperglycaemia common and powerful predictor) - Echo - CXR (alternative diagnoses) - Cardiac MRI - Coronary angiography gold standard
35
Within first six hours which is superior for detection of MI? Troponins or CK-MB?
Troponins
36
Timeline of troponin
Detectable 3-6 hours after infarction, peak at 12-24 hours, remains raised for 14 days
37
Test troponins when
Between 6-12 hours after onset of pain
38
For ACS, after aspirin and antithrombin therapy have been offered, do what?
Risk assessment, GRACE score
39
Management of NSTEMI/unstable angina
- Oxygen - Nitrates: if sublingual ineffective; IV or buccal - If pain continues morphine - Aspirin 300mg - If high risk (GRACE, secondary criteria, rise in troponin) - LMWH - IV nitrate - Beta blockers - If high risk: Glycoprotein IIb/IIa inhibitors
40
Management of STEMI
-Oxygen -Morphine -Aspirin+ticagrelor -PCI or thrombolytic drug -If PCI not available within 90mins, thrombolytic drug with any heparin -Nitrates; if ineffective, IV -Beta blockers -ACE inhibitors Monitor hyperglycaemia
41
Long-term management of STEMI
Discharge with - Aspirin - Clopidogrel (if intolerant prasugrel or ticagrelor, or warfarin if low risk of bleeding) - Beta blockers - ACEi - Nitrates - Statins
42
Which troponins are most specific to the heart?
I and T
43
Causes of raised troponin
MI, Right ventricular strain (from massive PE), sepsis, renal failure, burns SAH -change in troponin level is often more important than actual troponin level