Angina (CVS) Flashcards
Define Angina, two types and the difference
Angina is chest pain triggered by myocardial ischemia. Stable angina and unstable angina
Describe the difference between stable and unstable angina
Stable angina occurs on exertion and is always relieved by rest/ glyceryl trinitrate (GTN) spray. Unstable occurs at rest and is a form of ACS tf needing immediate management. This is bc their aetiology is different.
What are the risk factors of stable angina?
Age, family history, smoking, high chol, hypertension, diabetes, unhealthy diet, lack of exercise obesity, male, premature menopause
What is the aetiology of stable angina?
Stable angina happens as a result of a mismatch of myocardial oxygen supply and demand. Most commonly, stable angina is caused by CAD. CAD refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. When demand for myocardial o2 increases with exertion, narrowed arteries cannot meet this increased demand leading to myocardial ischaemia and pain.
What are the rarer causes of stable angina?
Valvular disease e.g. aortic stenosis, hypertrophic obstructive cardiomyopathy, hypertensive heart disease
What are the 3 clinical features of stable angina?
Chest pain/constriction that feels tight, dull or heavy that may radiate to arms, neck, jaw or back. Brought on by exertion. Alleviated by rest or GTN spray within 5 mins
What are the associated symptoms in stable angina?
Nausea, vomiting, clammy or sweaty
What are typical and atypical angina?
Typical angina is when all 3 clinical features are present and atypical angina is when only two are.
What are the basic investigations for suspected stable typical or atypical angina?
All patients should have the baseline investigations:
Physical exam - heart sounds, signs of HF, BMI
ECG (resting or exercise) - may show ST depression, other ischemic changes or signs of past MI. Normal does not exclude stable angina.
Blood tests - FBC and TFTs to exclude anaemia and hyperthyroidism as these exacerbate anginal symptoms. Hypothyroid is associated w/ CAD.
What is 1st line investigation for angina?
CT coronary angiogram (CT CA) - this is done if there is typical/atypical pain or if the ECG shows ischemic changes in chest pain with only 1 angina feature.
How is coronary angiography done?
An x ray imaging test that allows to view the coronary arteries. Involves injecting a contrast medium (dye) into a vein and taking CT images timed with heart beat to view the coronary arteries.
What are the 2nd and 3rd line investigations of stable angina?
If CTCA is inconclusive then:
Stress echo, myocardial perfusion SPECT, cardiac MRI for regional wall motion abnormalities. If these give inconclusive results, 3rd line is invasive coronary angiography
What are the differentials for stable angina and how we differentiate?
ACS (but stable angina is on exertion), GORD (stable angina is described as squeezing or pressure like pain while GORD chest discomfort feels like burning due to certain foods/alcohol/lying down)
Costochondritis (this pain is due to inflam of costal cartilage and feels sharp and can be done by pressing on chest)
Pleuritic chest pain (e.g. in PE, pneumonia - feels sharp and worse on inspiration)
What is the conservative management of stable angina?
Reducing risk factors to reduce athersclerotic process.
Smoking cessation, glycemic control, hypertension, hyperlipidemia, weight loss, alcohol intake
What is the basic medical management of stable angina?
Immediate symptom relief - GTN spray. Long term symptom relief - anti anginal medications. Secondary prevention of cardiovasc disease - aspirin
How is GTN spray used in stable angina and what are the side effects?
Used for rapid relief and just before activities that cause angina symptoms. Take one dose if feeling chest pain, take a second dose if pain has not eased after 5 mins, if pain has still not eased 5 mins after second dose or if it gets worse then call 999 as may indicate ACS.
SEs = headache, flushing, dizzy
What is the 1st line anti anginal medications for long term symptom relief.
Beta-blocker (bisoprolol) or calcium channel blocker (verapamil or diltiazem).
What is the 1st line anti angina meds for those who cannot tolerate both beta blocker or CaC blocker or there is contradincation
Monotherapy with:
Long acting nitrate e.g. ISMN
Nicorandil
Ivabradine
Ranolazine
What is 2nd line meds for stable angina?
beta blocker and long acting dihydropyridine CaC blocker (amlodipine or nifedipine)
What is 3rd line management for stable angina? When is this done?
beta blocker and long acting dihydropyridine CaC blocker and long acting nitrate. Here coronary revasc must be considered so PCI or CABG.
What is the secondary prevention of stable angina?
Aspirin 75mg once daily and statin 80mg once daily
Complications of stable angina?
ACS, arrhythmias
