Angina (stable + Unstable)

Question 1

Aetiology

Answer 1

Mycoardial iachaemia.
Usually atheroma.
Aortic stenosis
Hypertrophic cardiomyopathy 
Rarely anaemia, tachyarrhythmia, arthritis, small vessel disease.

Question 2

symptoms

Answer 2

Central chest tightness or heaviness.
May radiate to arms, neck, jaw, teeth.
Dyspnoea
Nausea
Sweating
Faintness
Triggers- exercise, emotion, cold weather, heavy meals.

Question 3

Definition

Answer 3

• stable- induced by exertion, relieved at rest or by nitrates in 5 mins.
• unstable- increasing frequency or severity on minimal exertion or at rest. Longer duration. No relief by nitrates. High risk MI.
• decubitus- precipitated by lying flat.
• variant- caused by CA spasm.

Question 4

Diagnosis

Answer 4

ECG usually normal, may show STD, flat or inverted T, signs of past MI.
Exclude eg anaemia, DM, hyperlipid, thyrotoxicosis, temporal arthritis.
Exercise test
Fucntional imaging

Question 5

Management

Answer 5

Modify RFs
Aspirin reduce platelet aggregation. 
BB reduce HR and contractility. 
Nitrates- GTN acutely, isosorbide mononitrate prohpylaxis oral. Reduce preload by venodilation. 
Long acting Ca antagonist reduce afterload by peripheral vasodilation. 
K channel activator 
Statins reduce LDL
Revascularisation- PCI or CABG

Question 6

Coronary blood flow

Answer 6

Epi to endocardium.
So subendocardial muscle most vulnerable to ischaemia.
CA’s compressed during systole so most CA flow during diastole, which is shortened more at high HR.
No collaterals between major As, some between smaller CAs and arterioles. New ones develop with ischaemia slowly.

Question 7

Coronary atherosclerosis

Answer 7

Plaques necrotic centre and fibrous cap.
Stable- thick cap, small necrotic core.
Vulnerable- large necrotic core, thin cap. More likely fissure= platelet clot then fibrin thrombus.
ACS= unstable angina, NSTEMI, STEMI.
Unstable angina eg just platelet agrregation.
NSTEMI eg small thrombus
STEMI eg thrombus occlusion complete.

Question 8

Signs

Answer 8

RFs eg HTN, corneal arcus, PVD absent pulses.
LV dysfunction.
Resting ECG normal.
Exercise ECG transient subendocardial ischaemia= STD. Positive test if STD over 1mm. Negative if target HR w/o ECG changes

Question 9

Explanation

Answer 9

• angina happens when one or sometimes more blood vessels supplying the heart muscle gets partially blocked. This means the part of muscle it supplies doesnt get enough oxygen and nutrients and becomes damaged. This causes pain. Also it means the hearts pumping is not completely normal and efficient so you might feel a bit dizzy and short of breath.
• angina can be managed very well, but the fact that there is a blockage of a heart vessel means there is a risk that it could get bigger or rupture and cause a hear attack.
• in terms of lifestyle it is very important to eat healthily, exercise, stop smoking and dont drink too much alcohol as these things will alll add to your risk of further heart problems.
• in terms of medication. You will need to take aspirin one term to reduce the risk of blood clots forming in your vessels. Also we will give you a spray for when you have an attack just to help relax the vessels to allow more blood to pass through. As well as this we will give you something to lower your cholesterol to stop any more blockage forming or getting worse. We can give you other drugs to reduce the amount of work your heart is doing. And if this doesnt work we can do things like put in a stent to hold the blocked vessel open.