Angina Pectoris Flashcards
ANgina
Reduced bloodflow - ischemia - pain
Types of Angina
Stable
Unstable
Prinzemetal (Vasoplastic)
Stable Angina
> 70% stenosis. Enough to supply at rest but not on exertion
always relieved by rest or glyceryl trinitrate (GTN)
Due to -
Atherosclerosis of >1 coronary arteries
Hypertrophic cardiomyopathy
High pressure -Aortic stenosis, HTN
Ischaemia to subendocardium- adenosine and bradykinin relese stimulate nerves- pain
lasts <10 mins
ST depression
Unstable angina
pain at exercise and rest From an atherosclerotic plaque rupture with thrombus occlusion Can progress to MI ST depression Ischaemic T wave
Vasoplastic Angina
May or may not have atherosclerosis
Ischaemia is from Coronary artery vasospasms
Transmural
treat with nitroglycerin, responds to CCB
Stable Angina investigations
CTCA CT Coronary Angiography Baseline - Physical Examination (heart sounds, signs of heart failure, BMI) ECG FBC (check for anaemia) U&Es (prior to ACEi and other meds) LFTs (prior to statins) Lipid profile Thyroid function tests (check for hypo / hyper thyroid) HbA1C and fasting glucose (for diabetes)
Management of stable angina
R – Refer to cardiology (urgently if unstable)
A – Advise them about the diagnosis, management and when to call an ambulance
M – Medical treatment
P – Procedural or surgical interventions
M – Medical treatment for stable angina
GTN - for immediate relief. take twice if not stopped call ambulance
1st Line
Beta blocker - Bisoprol 5mg ( if previous MI or HF)
Calcium channel blockers - amlodipine 5mg (if previous MI no HF)
2nd line -
Nicorandil or long acting nitrate
Ranoazine
Ivabradine
Secondary prevention
Statins - Atovarstatin
Aspirin 75mg
ACE inhibitors
Classes of Stable Angina
Class 1 – No angina with ordinary activity. Angina with strenuous activity
Class 2 – Angina during ordinary activity eg walking uphill, upstairs rapidly. Mild limitation of activities
Class 3 – Angina with low levels of activity eg ; walking 50-100 yards on the flat, climbing one flight of stairs. Marked restriction of activities.
Class 4 – Angina at rest or with any level of exercise
P – Procedural or surgical interventions of Stable Angina
Percutaneous Coronary Intervention (PCI) with coronary angioplasty
Coronary Artery Bypass Graft (CABG)
Making a Diagnosis of ACS
◉If there is ST elevation or new left bundle branch block the diagnosis is STEMI.
◉If there is no ST elevation then perform troponin blood tests:
◉If there are raised troponin levels and/or other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI
◉If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain
ACS Symptoms
Central, constricting chest pain associated with:
Nausea and vomiting Sweating and clamminess Feeling of impending doom Shortness of breath Palpitations Pain radiating to jaw or arms Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina. Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”.
ECG Changes in Acute Coronary Syndrome
STEMI:
ST segment elevation in leads consistent with an area of ischaemia
New Left Bundle Branch Block also diagnoses a “STEMI”
NSTEMI:
ST segment depression in a region
Deep T Wave Inversion
Pathological Q Waves (suggesting a deep infarct – a late sign)
alternative causes of raised troponins:
Chronic renal failure Sepsis Myocarditis Aortic dissection Pulmonary embolism
ACS investigations
Troponins Physical Examination (heart sounds, signs of heart failure, BMI) ECG FBC (check for anaemia) U&Es (prior to ACEi and other meds) LFTs (prior to statins) Lipid profile Thyroid function tests (check for hypo / hyper thyroid) HbA1C and fasting glucose (for diabetes) Plus:
Chest xray to investigate for other causes of chest pain and pulmonary oedema
Echocardiogram after the event to assess the functional damage
CT coronary angiogram to assess for coronary artery disease
Acute STEMI Treatment
Patients with STEMI presenting within 12 hours of onset should be discussed urgently with local cardiac centre for either:
Primary PCI (if available within 2 hours of presentation) Thrombolysis (if PCI not available within 2 hours)
Acute NSTEMI treatment
BATMAN
B – Beta-blockers unless contraindicated Bisoprolol 2.5mg od
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
M – Morphine titrated to control pain
A – Anticoagulant: Fondaparinux (unless high bleeding risk)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
Give oxygen only if their oxygen saturations are dropping (i.e. <95%).
GRACE Score to assess for PCI in NSTEMI
This scoring system gives a 6-month risk of death or repeat MI after having an NSTEMI:
<5% Low Risk
5-10% Medium Risk
>10% High Risk
If they are medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.
Complications of MI (Heart Failure DREAD)
D – Death
R – Rupture of the heart septum or papillary muscles
E – “Edema” (Heart Failure)
A – Arrhythmia and Aneurysm
D – Dressler’s Syndrome
Secondary Prevention Medical Management (6 As) after PCI
Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Dual antiplatelet duration will vary following PCI procedures depending on the type of stent that was inserted. This is due to a higher risk of thrombus formation in different stents.
Secondary Prevention Lifestyle
Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation (a specific exercise regime for patients post MI)
Optimise treatment of other medical conditions (e.g. diabetes and hypertension)
Dressler’s Syndrome
This is also called post-myocardial infarction syndrome. It usually occurs around 2-3 weeks after an MI. It is caused by a localised immune response and causes pericarditis (inflammation of the pericardium around the heart). It is less common as the management of ACS becomes more advanced.
It presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely a pericardial tamponade (where the fluid constricts the heart and prevents function).
A diagnosis can be made with an ECG (global ST elevation and T wave inversion), echocardiogram (pericardial effusion) and raised inflammatory markers (CRP and ESR).
Management is with NSAIDs (aspirin / ibuprofen) and in more severe cases steroids (prednisolone). They may need pericardiocentesis to remove fluid from around the heart.
Treatment – STEMI/New LBBB
reperfusion within 12 hrs of onset of symptoms
PCI + stent
Fibrinolytic therapy
Rescue Angioplasty
After-
BB
ACE /ARBs
Statins
Treatment of Unstable Angina and NSTEMI
To prevent new thrombus formation : LMWH – subcut e.g. Fondaparinux Aspirin 75mg daily after loading dose (300mg) Clopidogrel 75mg daily after loading dose (300mg) To reduce myocardial oxygen demand: Beta blocker Consider IV/buccal nitrate Treat arrythmias/heart failure promptly
