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Cardiology > Angina Pectoris > Flashcards

Angina Pectoris Flashcards

0
Q

Causes

A

1) decrease coronary blood flow by mechanical obstruction { atherosclerosis - coronary spasm - coronary thrombosis / embolism -vasculitis }
2) decrease the flow of oxygenated blood to myocardium { hypoxia - anemia }
3) increase oxygen demand { left ventricular hypertrophy * HTN * AS }

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1
Q

Angina pectoris

A

Episodic clinical syndrome due to transient myocardial ischemia characterized by chest pain with no cardiac tissue damage

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2
Q

Clinical picture

A

Symptoms

1) chest pain
2) risk factors are positive
3) May be presented with dyspnea, fatigue, faintness ( angina equivalents)

Signs
1) heart examination is mostly normal
2) S4 (apex) due to ventricular compliance
3) murmur of MI ( ischemic papillary muscle)
4 other manifestations { xanthelasma in hyperlipidemia , anemia, ….}

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3
Q

Angina pectoris Chest pain

A

heaviness, increase by exertion, decrease by rest or nitrates

–> retrosternal radiates to { jaw, neck, left shoulder, left arm, or epigastrium}

  • Anginal pain never to be : localized - stitching or throbbing - < 30 sec or >30 min (except unstable angina)
  • Anginal pain PPT by : exertion - cold exposure - heavy meals - vivid dreams( nocturnal angina)
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4
Q

Investigations

A

1) ECG ( resting ECG usually normal)–> Stress test
S-T segment depression
T- wave inversion

2) cardiac scan ( thallium , technetium )
Thallium with exercise
Heart can be stressed with dobutamine

3) echo and dobutamine echo
4) coronary angiography
5) TLC/ ESR/ CK enzymes
6) lipid profile, serum homocysteine, CRP, blood sugar

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5
Q

Indications for coronary angiography

A

1) stable angina refractory to medical therapy
2) unstable angina
3) strongly positive stress test
4) post infarction angina
5) unexplained / significant chest pain

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6
Q

Clinical types of angina

A

Stable angina

Unstable angina

Variant angina

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7
Q

Stable angina

A

It occurs when coronary perfusion is impaired by fixed stable atheroma of the coronary artery

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8
Q

Criteria of pain in stable angina

A

Short duration ( 5-10 min)
Induced by exertion and emotional stress
Reduced by rest and nitrates

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9
Q

Start - up angina

A

Anginal pain during start of walking then disappear despite greater effort

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10
Q

High risk Category of stable angina

A
  • post infarction angina
  • poor effort tolerance
  • ischemia at low work load
  • left main or three vessel disease
  • poor left ventricular function
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11
Q

Low risk Category of stable angina

A
  • predictable exertional angina
  • good effort tolerance
  • ischemia only on high work load
  • single vessel or minor two vessel disease
  • Good left ventricular function
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12
Q

Treatment of stable angina

A
  • low risk [ medical treatment ]
    B.B. /Ca. Ch. blockers /Nitrates /antiplatelete
  • high risk [ coronary angio]
  • left main or three vessel disease CABG
  • single or two vessel disease
    Medical
    PTCA
    CABG
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13
Q

Unstable angina
Crescendo angina
Pre infarction angina
Intermediate coronary syndrome

A

Complicated atheromatous plague + coronary spasm

Prolonged pain at rest , frequent , poor response to nitrates

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14
Q

Treatment of unstable angina

A

Medical emergency

1) hospitalization
2) initial treatment
- BB atenolol 50-100 mg/12 hr (verapamil is an alternative)
- Ca Ch B amlodipine ( can be added to BB as it cause unwanted tachycardia if used alone)
- nitrates Glyceryl trinitrate infusion 0.6-1.2 mg/hr
- antiplatelete Aspirin 75-325 mg/d
- anticoagulant LMWH for 3-5 days
3) then angiography must be done with planning for:
- CABG
- Coronary angioplasty PTCA

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15
Q

Indications for CABG

A

Three vessels coronary artery disease

Two vessels disease involving the proximal left anterior descending branch

Left main stem artery disease

Symptomatic Ptn despite optimal medical treatment and whose disease is not suitable for PTCA

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16
Q

Indications for PTCA

A

Single or two vessels disease

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17
Q

Postoperative medication after PTCA with stent insertion

A

Aspirin and ticlopidine

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18
Q

Triple coronary artery bypass graft

A

Reversed saphenous vein graft for circumflex and right coronary

Left internal mammary artery for left descending branch or left main coronary

19
Q

Variant angina subtypes

A

Pure vasospastic angina

Prinzmetal’s angina

20
Q

Pure vasospastic angina

A

Coronary spasm in the presence of angiographically normal coronary arteries

Young age
Risk factors … Negative
Not related to exertion

21
Q

Diagnosis of pure vasospastic angina

A

Hospitalization

CCU

Provocative test ( give ergonovine or acetylcholine IV or induction of hyperventilation with ECG monitoring)

Patient suffers from variant angina shows chest pain and ECG changes

22
Q

Treatment of variant angina

A

B.B. Are contraindicated

Aspirin may exacerbate the vasospastic angina

Give Ca Ch B OR. Nitrates

23
Q

Prinzmetal’s angina

A

Coronary spasm at site of atheromatous plague

24
Q

Decubitus angina

A

Occur at lying down

With impaired left ventricular function

25
Q

Nocturnal angina

A

Occur at night

Provoked by vivid dreams

26
Q

Cardiac syndrome X

A

Refers to patients with good history of angina positive exercise test with normal angio
This is due to abnormalities of the coronary microcirculation

27
Q

Angina with normal coronary arteries

A

Coronary spasm ( <1% of all cases of angina)

Cardiac syndrome X

28
Q

Acute coronary syndromes

A

Myocardial infarction and unstable angina

29
Q

Treatment of angina pectoris

A

During the attack

    • rest , O2 therapy
    • nitrate sublingual tablets
    • reassurance and sedation

In between attacks

    • diet modification
    • stop smoking , moderation of life
    • aspirin 75-150 mg/d
    • treatment of risk factors ( DM, HTN, hyperlipidemia)
    • drug therapy
30
Q

Nitrates mechanism of action in angina

A

Venodilators –>decrease VR –> decrease preload –>decrease ventricular wall tension

Coronary vasodilation

31
Q

Uses of nitrates

A

Angina pectoris

Esophageal spasm and achalasia

Relief of pulmonary venous congestion

Myocardial infarction

Biliary colic and hypertensive encephalopathy

32
Q

Side effects of nitrates

A

Headache
Hypotension
Chronic use cause tolerance

33
Q

Routes of administration for nitrates

A

Sublingual tablets 300-500 ug glyceryl trinitrate

Sublingual spray glyceryl trinitrate 400ug/puff

Oral isosorbide 10-20 mg/8 hrs (dinitra)

Amyl nitrate ampule for inhalation

Ointment (2% nitroglycerin ointment ) at night

IV used in unstable angina and myocardial infarction

Transdermal patches

34
Q

Things to remember about nitrates

A

Chronic use cause tolerance

Long acting nitrate ( isosorbide mononotrate) are preferred, 20-60 mg once or twice/d

Sildenafil ( Viagra ) should not be given to patient taking nitrates

35
Q

Beta-blocker action

A

Negative inotropic
Negative chronotropic

Decrease oxygen consumption
Increase time of coronary filling

36
Q

Types of B. B.

A

Non selective ( first generation )

  • propranolol ( indral) 40-320 mg/d
  • nadolol ( corgard) 80 mg/d

Selective ( second generation )

  • atenolol ( tenormin) 25-200 mg/d
  • metoprolol (betalock) 50-100 mg/d
  • bisoprolol (concor) 5-10 mg/d

Third generation with vasodilatation effect. Carvidilol ( dilatrend 25 mg/d)

37
Q

Cardiovascular uses of B. B.

A

Hypertension

Angina

Arrhythmia

Cyanotic spills ( F4)

Mitral valve prolapse

38
Q

Non cardiovascular uses of B. B.

A

Thyrotoxicosis

Anxiety

Portal hypertension

Familial tremors

Parkinsonism

Migraine

Glaucoma ( timolol)

39
Q

Side effects of B. B.

A

Bradycardia

Heart block

Heart failure

Night mares

Depression

Fatigue

Importance

Bronchospasm

Angina with sudden withdrawal

40
Q

Calcium channel blockers classification

A

Dihydropyridines

  • nifedipine, nicardipine ( short acting)
  • amlodipine ( long acting)
  • cinnarzine ( stugeron) cerebral vasodilator
  • nimodipine ( nimotop) used in subarachnoid Hge

Non dihydropyridines
- verapamil - diltiazem

41
Q

Actions of Ca ch b

A

Inhibit Ca influx in:
Heart
- negative inotropic
- antiarrythmic

Blood vessels

  • coronary VD
  • cerebral VD
  • peripheral VD

Bronchial tree– bronchodilator

42
Q

Nefidipine ( adalat ) 10-20 mg t.d.s.

Actions?
Uses?
Side effects?

A

Peripheral & coronary VD
** no negative inotropic & chronotropic effect

Can be used in IHD with heart block
– better combined with BB … Undesirable reflex tachycardia

Side effects : headache tachycardia peripheral edema

43
Q

Verapamil

Dose?
Actions?
Uses?
Side effects?

A

Isoptin 80 mg/8hr or 240 mg slow released tablets once or twice daily

Antiarrythmic
Negative inotropic
Coronary VD

Used in IHD with arrhythmia not HF

Side effects. { HF - H block - constipation } should not be used with BB

44
Q

Diltiazem

Dose?
Actions?

A

Delaytiazem 60-180 mg/12hr

Coronary VD more than verapamil and negative inotropic less than verapamil

45
Q

Intractable angina

A

Ptn remain symptomatic despite medication
Not suitable for revascularization

TMR trans myocardial laser revascularization

Cardiology (3 decks)

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