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SPM- Cardiology > Angina Pectoris > Flashcards

Angina Pectoris Flashcards

1
Q

When is chest discomfort experienced in patients with angina?

A

On exertion or emotional stress

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2
Q

What causes the discomfort patients with angina experience?

A

One exertion the oxygen demand of the myocardium increases. Due to a narrowed lumen the flow of of the blood cannot adequately increase to meet the demands of the myocardium and this leads to the production of lactic acid- this is what causes the discomfort. It is called demand ischaemia

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3
Q

How can the the cause of angina be subdivided?

A

Atherosclerotic disease
Vasospasm- Prinzmetal Angina
Increased oxygen demands of the myocardium- aortic stenosis, hypertrophic cardiomyopathy, HTN

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4
Q

What percentage stenosis usually leads to angina?

A

> 70%

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5
Q

What is the difference betweens stable and unstable angina?

A

Stable Angina- Pain experienced on exertion

Unstable Angina- Pain experienced at rest, not eased by GTN spray

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6
Q

Why might aortic stenosis lead to angina pain?

A

Increased resistance to flow during systole due to the stenosed vessel. Myocardium hypertrophies to overcome this increased resistance which leads to increased oxygen demands and demand ischaemia if blood supply inadequate.

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7
Q

Why might angina from emotional stress persist for longer?

A

Due to circulating adrenaline which increase HR and so the oxygen demands of the myocardium increase

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8
Q

What triggers unstable angina?

A

Thrombosis- atherosclerotic plaque rupture which leads to clot formation overlying it

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9
Q

What is prinzmetal angina?

A

Angina that occurs due to vasospasm of the coronary arteries

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10
Q

What drug can cause coronary artery vasospasm?

A

Cocaine

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11
Q

What ischaemic changes might be seen on an ECG in someone with angina on exertion?

A

ST depression
T wave inversion

Note- this these are the same changes seen in NSTEMI and Unstable angina, or the ECG may be normal

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12
Q

What is used to treat angina?

A

Glyceryl trinitrate- sublingual preparation

This is taken when episodes of discomfort come on and rapidly reduces the pain by causes vasodilation

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13
Q

What is a contra-indication to GTN?

A

Hypotension

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14
Q

What are some triggers to angina?

A

Exertion
Emotional Stress
Exposure to cold
Eating a large meal

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15
Q

What are some adverse effects of GTN?

A

Flushing
Headaches
Dizziness

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16
Q

What important advice should be given to angina patients about managing their pain?

A

If after a second dose of GTN (wait 5 minutes after 1st and 2nd) they should call 999

Or earlier if the pain is intensifying or the patient is unwell

Likely ACS picture

17
Q

What medications should be given to patients with angina?

A

GTN

Beta blocker or a calcium channel blocker to reduce the symptoms by decreasing HR and myocardial oxygen demands

18
Q

What is the gold standard investigation to assess for coronary artery narrowing?

A

CT Coronary Angiogram- this is the main investigation if no prior history of CVD

19
Q

What investigations would you request for a patient with angina pain?

A

Bloods-
FBC- Anaemia can cause low oxygen supply to myocardium
U and Es- Important to know prior to starting medication, especially ACEi or ARBs
LFTs- Important to know before starting a statin
Lipid Profile- Modifiable risk factors
TFTs- Hyperthyroidism can cause tachycardia
HBA1c and Fasting Glucose- risk factor for atherosclerotic disease

ECG- Ischaemic changes
ECHO- If indicated to rule out structural issues and valve function
CXR- rule out possible respiratory pathology, cardiomegaly

20
Q

What would you want to assess on examination of a patient with angina?

A

Blood pressure- increased afterload
Heart sounds- Aortic stenosis?
Signs of anaemia- low oxygen capacity of blood
Signs of heart failure- JVP, Lung Bases, Pitting oedema
Quick resp assessment to rule out resp causes of chest pain

21
Q

How can the RAMP mnemonic help to remember the management of angina?

A

Refer to cardiology
Advice when to call an ambulance- if two doses of GTN fail to improve the pain, or intense/worsening picture or unwell
Medical treatment
Procedural or surgical investigations

22
Q

What are the three aims of the medical management?

A

Immediate relief- GTN
Long term relief- Beta blockers, calcium channel blockers
Secondary prevention- Statins, Glycaemic control, ACEi, Aspirin (reduce risk of MI)

23
Q

Summarise the three aims of medical management of angina?

A

Immediate relief
Long term relief
Secondary prevention

24
Q

What is used for immediate symptomatic relief of angina pain?

A

GTN

25
Q

What is used for long term symptomatic relief?

A

Beta blocker- e.g. Bisoprolol 5mg OD
Calcium channel blocker- Amlodipine 5mg OD

May be combined

26
Q

What is a long acting nitrate?

A

Isosorbide mononitrate

27
Q

What surgical intervention may be considered?

A

PCI or coronary angioplasty

28
Q

Who is offered surgical interventions for angina?

A

Extensive or proximal disease on CT angiography

Or failure to control symptoms with optimal medical therapy

29
Q

Outline roughly how PCI is performed

A

Access via brachial or femoral artery
Directed to coronary arteries and diseased vessel
Ballon used to dilate the artery
Stent put in place to keep lumen patent

30
Q

What are stents lined with to prevent luminal narrowing due to cell proliferation?

A

Chemotherapy agents/anti-proliferative agents

31
Q

Where is the graft vein often taken for CABG?

A

Great saphenous vein

32
Q

If you are examining a patient with suspected CVD where should you look for scars?

A

Brachial artery at the cubital fossa
Femoral Artery- Mid inguinal point
Midline sternotomy scar
Distribution of the saphenous veins to check for vein harvest

33
Q

What should be given for secondary prevention in angina patients?

A

ACEi
Statins
Aspirin

Note- people with PVD should already be taking clopidogrel and they should continue on this

34
Q

What should beta blockers never be combined with?

A

Verapamil or other non-DHPs calcium channel blockers e.g. Diltiazem but this is less cardioselective

Also termed rate limiting calcium channel blockers and they should not be prescribed with a beta blocker as they can cause severe bradycardia and heart failure

35
Q

After stenting what should the patients stay on for around 12 months?

A

Dual platelets

Aspirin and Clopidogrel/Ticagrelor

36
Q

When should patients with angina be referred to cardiology?

A

Failure to control symptoms despite maximal first line medical therapy
Ischaemic changes on ECG

Note if any features of unstable angina this requires an urgent admission

37
Q

What are some 2nd line medications that can be offered to patients for long term symptoms relief?

A

Long acting nitrate
Ivabradine
Nicoradil
Ranolazine

(Likely given by specialist)

SPM- Cardiology (4 decks)

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