Angina Pectoris Flashcards
What are 3 features of angina?
1 Constricting/heavy discomfort to the chest, jaw, neck, shoulders or arms
2 Symptoms brought on by exertion
3 Symptoms relieved within 5 min by rest or glyceryl trinitrate
what is typical vs atypical angina?
Typical angina has all features of angina
Atypical has only 2 features of angina
If only 0-1 = non anginal chest pain
What can precipitate angina?
Cold weather Emotion Heave meals Exertion Severe anaemia Cardiomyopathy
What are associated symptoms with angina?
Dyspnoea
Nausea
Sweatiness
Faintenss
What kind of pain would make you think angina is less likely?
Continuous pain
Pleuritic pain
Associated with swallowing
Associated with palpations, dizziness or tingling
What are causes of angina?
Atheroma Anaemia Coronary artery spasp Aortic stenosis Tachyarythmias Cardiomyopathy
Describe the process of atherosclerosis
Endothelial dysfunction
High levels of lipid in the blood leads to deposition of lipid in the tunica intimacy of arteries forming a fatty streak.
Leucocytes and smooth muscle cells migrate into the arterial wall
Foam cells form
Extracellular matrix is degraded
The atherosclerotic plaque grows
It can be disrupted exposing the blood to thrombogenic material leading to complete occlusion of a vessel
What are the types of angina?
Stable angine: induced by effort, relieved by rest
Unstable angina: Angina of increasing frequency or severity, occurs on minimal exertion or at rest, associated with increased risk of MI
Describe stable vs unstable angina
Stable: induced by exercise, relived by rest or GTN
Unstable - angina that changes or worsens:
1. occurs at rest (or with minimal exertion)
2. Severe and of new onset
3. Occurs with a crescendo pattern
Stable angina - developing atheroma is protected with fibrous cap.
In unstable angina this cap may rupture allowing blood clots to precipitate and further decrease the area of the coronary vessel lumen.
What is decubitus angina?
Precipitated by lying flat
What tests would you do for chest pain?
Bedside
ECG - usually normal but may show ST depression, flat or inverted T waves
Exercise ECG - for ischameic changes
Bloods
FBC, U&E, TFT, lipids, HbA1c
Imaging: Angiography - cardiac CT with contrast or trans catheter Stress echo CXR Cardiac MRI
What advice would you give to someone with angina?
Stop smoking Exercise Low fat diet Lose weight Optimise blood pressure Control diabetes well
Give a management plan for angina
Lifestyle advice
75mg aspirin daily if not CI
Hyperlipidaemia - statin
ACE inhibitor
PRN glyceryl trinitrate
Antianginal medication
1: Beta blocker / CCB
What is used for symptoms relief in angina? How does this work? SE? What should you advise about this?
GTN spray/sublingual
Increases amount of NO in blood which relaxes SMC in vessels causes vasodilation
SE: Hypotension, headache
If pain is still present, repeat dose, wait 5min after second dose - call ambulance if still painful
What is the pharmacological management for angina?
1 beta blocker e.g. atenolol/bisprolol
2 Calcium antagonist e.g.. amlodipine
3 Long-acting nitrates: isosobide mononitrate
4 Ivabrandine - reduces HR, must be in sins rhythm
Nicorandil - potassium channel activator
What interventions can be considered when medical management is inadequate? Compare the two
Revasularisation
Percutaneous coronary intervention - balloon is inflated in the stenosed vessel, opening the lumen. Stent is inserted to reduce risk fo re-stenosis. Dual anti platelet therapy (aspirin and clopidogrel) recommended for 12 months after stent insertion to reduce the risk of stent thrombosis.
CABG - saphenous vain or radiating artery used to create bypass graft for stenosed vessel
CABG less likely to need repeat revascularisation compared with PCI and better outcomes for multi vessel disease but
Recovery is slower and patient is left with two large wounds
What is PCI and CABG? What is recommended after a PCI?
Revasularisation
Percutaneous coronary intervention - balloon is inflated in the stenosed vessel, opening the lumen. Stent is inserted to reduce risk fo re-stenosis. Dual anti platelet therapy (aspirin and clopidogrel) recommended for 12 months after stent insertion to reduce the risk of stent thrombosis.
CABG - saphenous vain or radiating artery used to create bypass graft for stenosed vessel
What are 3 important investigations for ischaemic heart disease
Exercise ECG - monitor for ischaemic changes
Angiography - cardiac CT with contrast or transcatheter
Functional imaging - stress echo, myocardial perfusion scintigraphy
How would you investigate/treat typical angina in a patient with previous IHD?
Treat as stable angina
Use non invasive testing for further confirmation - exercise ECG
How would you investigate /treat typical and atypical angina?
CT angiography
Funcitonal imaging as 2nd line
Transcatheter as 3rd line
What could cause angina in a patient unlikely to have IHD?
Severe anaemia
Cardiomyopathy
Describe vasospastic angina.
Angina due to coronary artery spasm. Pain usually at rest and resolves rapidly with GTN.
ECG during pain shows ST elevation.
Triggers include cocaine, amphetamine, marijuana, low magnesium and iatrogenic
What can cause angina recurrence after CABG?
Graft failure - blockage of graft or another vessel
Progression of angina to unstable angina
