Angina and Coronary Artery Disease Flashcards
What is angina?
Symptomatic, reversible myocardial ischaemia
What are the symptoms of angina?
- Constricting / Heavy discomfort in chest, jaw, neck, shoulders or arms
- Symptoms brought on by exertion
- Symptoms relieved by rest or GTN within 5 minutes
What is the difference between typical angina, atypical angina and non-anginal chest pain?
Typical Angina
- all 3 symptoms
Atypical Angina
- 2 symptoms
Non-anginal Chest Pain
- 1 symptom
What is the management of angina?
- GTN spray
- Beta-blockers and/or Calcium channel blocker
What is the advice for a further angina attack?
- Stop what you are doing and rest
- Use GTN
- Take 2nd dose of GTN after 5 mins if pain has not eased
- Call 999 if pain has not eased after anther 5 mins (15 mins in total) or if pain intensifies/feel unwell
What are the risk factors of coronary artery disease?
- Age
- Male gender
- Hyperlipidaemia
- Diabetes
- Smoking
- Hypertension
What parts of the patient history are relevant to diagnosing CAD?
- Con-current diagnosis of CAD
- Stable angina, previous MI etc. - Con-current diagnosis of atherosclerotic atrial disease
- Ischaemic stroke, peripheral vascular disease or renovascular disease - Family Hx of coronary artery or atherosclerotic arterial disease
What would show up on a chest examination?
Heart murmurs
How are heart murmurs transmitted?
Blood flow remains turbulent after it passes through structural defect, so the murmur will continue to be heard in the direction that turbulent blood is flowing
What is the S1 sound?
First heart sound
- Caused by closure of mitral and tricuspid valves
- Start of systole in ventricles
What is the S2 sound?
Second heart sound
- Caused by closure of aortic and pulmonary valves
- End of systole and start of diastole
What is the S3 sound?
Third heart sound
- Caused by diastolic filling of the ventricle
What is the S4 sound?
Fourth heart sound
- Caused by atrial contraction against a stiff ventricle
- coincides with P-wave on ECG
When is S3 heard?
Left ventricular failure
Constrictive pericarditis
Mitral regurgitation
When is S4 heard?
Aortic stenosis
HOCM
Hypertension
What murmurs are heard in systole?
Aortic and pulmonary stenosis
Mitral and tricuspid regurgitation
Mitral valve prolapse
What murmurs are heard in early diastole?
Aortic and pulmonary regurgitation
What murmurs are herd in mid-late diastole?
Mitral and tricuspid stenosis
When do you auscultate with the bell and diaphragm?
Bell
- Low pitched sounds
Diaphragm
- High pitched sounds
Where do you auscultate heart sounds?
Aortic - second right intercostal space (ICS), right sternal border
Pulmonary - second left intercostal space (ICS), left sternal border
Tricuspid - Fourth left ICS, left sternal border
Mitral/Apex - Fifth ICS, left mid-clavicular line
What is an ejection murmur?
Due to turbulent forward flow through narrowed or irregular valves or outflow tracts
What is a regurgitant murmur?
Represent retrograde or abnormal flow into chambers that are at lower resistance.
Give an example of a ejection murmur
Aortic stenosis
Pulmonary Stenosis
Give an example of a regurgitant murmur
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defects
Aortic Stenosis
- Heart cycle
- Character
- Loudest on…
- Location
- Radiates to…
- Systolic
- Crescendo-descrescendo
- Expiration and sitting forwards
- 2nd intercostal space, right sternal edge
- Neck (carotid)
Mitral regurgitation
- Heart cycle
- Character
- Loudest on…
- Location
- Radiates to…
- Sytolic
- Pansystolic
- Expiration, using the bell and the left lateral decubitus position
- Apex
- Axilla
Aortic regurgitation
- Heart cycle
- Character
- Loudest on…
- Location
- Radiates to…
- Early diastolic
- Decrescendo
- Expiration whilst holding breath, sitting forwards
- 4th intercostal space, left sternal edge
- Left sternal edge
Mitral stenosis
- Heart cycle
- Character
- Loudest on…
- Location
- Mid/late diastole
- Rumbling, decrescendo murmur after an opening snap in diastole
- Expiration, using the bell and the left lateral decbitus position
- Apex
What can cause mitral stenosis?
Rheumatic heart disease
Infective endocarditis
What is mitral stenosis associated with?
Malar flush
LV hypertrophy
Atrial fibrillation
What is malar flush?
plum-red discolouration of the cheeks due to the back pressure of blood into the pulmonary system causing increased CO2 and vasodilation
How can mitral stenosis cause LV hypertrophy?
When pushing against stenotic valve, muscle has to try harder -> hypertrophy
How can mitral stenosis cause atrial fibrillation?
Atria struggles to push blood through stenotic valve causing strain and electrical disruption
What can cause mitral regurgitation?
Idiopathic weakening of valve with age Ischaemic heart disease Infective endocarditis Rheumatic heart disease Connective tissue disorders
What is mitral regurgitation associated with?
Congestive cardiac heart failure
How can mitral regurgitation cause heart failure?
Leaky valve reduced ejection fraction -> causes backlog of blood that is waiting to be pumped through left side of heart
What can cause aortic stenosis?
Idiopathic aged related calcification
Rheumatic heart disease
What is aortic stenosis associated with?
left ventricular hypertrophy
What can cause aortic regurgitation?
Idiopathic age related weakness
Connective tissue disorders
What is aortic regurgitation associated with?
Corrigan’s pulse
Heart failure
What is corrigan’s pulse?
a collapsing pulse that rapidly appears and disappears as blood is pumped out by ventricles and then immediately flows back through the aortic valve into the ventricles
How can aortic regurgitation cause heart failure?
Back pressure of blood waiting to get through left side of heart
What is cardiovascular disease (CVD)?
Decreased blood flow to the heart, brain and body caused by atheroma or thrombosis
What is the pathophysiology of CVD?
Plaques of fatty atheroma build up with causes arterial narrowing, or triggers a local thrombosis (blood clot) which blocks blood flow
What are the risk factors for CVD?
Lower socioecenomic status South Asian ethnicities Smoking Poor diet High cholesterol High BP Low physical activity Obesity Diabetes High alcohol consumption
