B.5 Stable Coronary Artery Disease Flashcards
B.5 Stable Coronary Artery Disease
define
Angina: Chest pain resulting from myocardial ischemia (necrosis of myocytes has not yet occurred) due to narrowing (e.g., thrombus or spasm like in Prinzmetal angina) of the coronary artery.
Stable angina: A form of angina that arises during physical exertion, mental stress, or exposure to cold, and typically subsides within 20 minutes of rest or after using nitroglycerin.
Stable coronary artery disease: Refers to a reversible supply/demand mismatch.
Eiology: The primary cause is atherosclerosis
B.5 Stable Coronary Artery Disease
pathophys
Myocardial Oxygen Supply-Demand Mismatch
Definition: The difference between the amount of oxygen supplied to the myocardium and the amount it requires.
Factors Reducing Oxygen Supply:
- Coronary atherosclerosis
- Vasospasms
- Increased heart rate
- Anemia
Factors Increasing Oxygen Demand:
- Increased heart rate
- Increased afterload
- Anemia
B.5 Stable Coronary Artery Disease
Etiology
- Atherosclerosis → plaque buildup in coronary arteries
- ↓ Coronary blood flow during ↑ demand (e.g. exertion)
- Myocardial ischemia without infarction
- Reversible → pain stops when demand ↓ or vasodilation ↑
B.5 Stable Coronary Artery Disease
clinical features of angina
Angina is the primary symptom of coronary artery disease (CAD). Patients typically become symptomatic when the degree of coronary stenosis exceeds 70%.
Commonly experienced as:
- Retrosternal chest pain or pressure
- Pain may radiate to the left arm, neck, jaw, epigastric region, or back.
- Pain is not influenced by body position or breathing.
- No tenderness of the chest wall.
- Pain may gradually increase in intensity.
- May present as gastrointestinal discomfort.
- Could be absent in elderly or diabetic patients.
Other Symptoms:
- Dyspnea
- Dizziness, palpitations
- Restlessness, anxiety
- Autonomic symptoms (e.g., diaphoresis, nausea, vomiting, syncope)
B.5 Stable Coronary Artery Disease
Stable angina Clinical
- Symptoms are reproducible and predictable.
- Symptoms typically subside within minutes after resting or using nitroglycerin.
- Common triggers include mental or physical stress, as well as exposure to cold.
B.5 Stable Coronary Artery Disease
Canadian Cardiovascular Society grading of angina pectoris
CCS Classification of Angina:
I: Strenuous exercise
II: Slight limitation during normal activities
III: Limitations in daily activities
IV: Constant limitations
B.5 Stable Coronary Artery Disease
DX
Laboratory Tests: Check for precipitating factors, primarily Hb, glucose, and lipids.
- ECG: Typically shows no abnormalities after attacks; stress ECG may reveal findings.
- Additional Tests: Include myocardial scintigraphy and stress echocardiography (with low-dose dobutamine).
- Risk Stratification: Conduct based on clinical assessment, exercise testing, left ventricular function, and potential results from coronary angiography.
B.5 Stable Coronary Artery Disease
pharma TX
Medications ABCDE
- A: Aspirin (Clopidogrel if contraindicated) and anti-angina treatment (NTG sublingually as needed for relief).
- B: Beta-blockers (or ACE inhibitors in previous CVD, or CCB if BP controlled).
- C: Smoking cessation and management of cholesterol (target LDL < 1.8 mmol/L).
- D: Diabetic control.
- E: Education and preventive measures.
B.5 Stable Coronary Artery Disease
Surgical TX
Indications for Coronary Angiography:
- Class III/IV effort angina pectoris (according to CCS).
- Therapy-resistant AP.
- Symptoms of severe coronary artery disease (CAD).
- Angina following revascularization.
- Decreased left ventricular function (EF).
Revascularization may be considered based on the following conditions:
- Severe symptoms.
- Changes in exertional capacity.
- Failed medical therapy.
- High-risk coronary anatomy.
- Significant left ventricular dysfunction.
B.5 Stable Coronary Artery Disease
define Vasospastic Angina
Vasospastic Angina:
Angina resulting from temporary coronary spasms, often occurring near areas of coronary stenosis.
- Not influenced by physical exertion (can also occur at rest).
- Typically occurs early in the morning.
B.5 Stable Coronary Artery Disease
Vasospastic Angina Etiology
Etiology:
- Cigarette smoking; use of stimulants (e.g., cocaine, amphetamines), alcohol, or triptans.
- Stress, hypertension, and exposure to cold.
- Linked to other vasospastic conditions (e.g., Raynaud phenomenon, migraine headaches).
- Typical atherosclerotic risk factors (excluding smoking) are not relevant to vasospastic angina.
B.5 Stable Coronary Artery Disease
Vasospastic Angina Epidemiology
Epidemiology:
- Most common in the Japanese population, particularly among young women.
- Average age of onset: 50 years.
B.5 Stable Coronary Artery Disease
Vasospastic Angina DX
- Reversible ST elevation on ECG (consider using a Holter monitor to observe transient ST changes).
- No troponin I or troponin T elevations on serial tests.
- Coronary spasms observed on angiography help confirm the diagnosis.
B.5 Stable Coronary Artery Disease
Vasospastic Angina TX
- Lifestyle modifications, particularly smoking cessation.
- Calcium channel blockers (CCBs): first-line treatment for acute attacks and prophylaxis.
- Long-acting nitrates.
- Avoid the use of beta-blockers.
B.5 Stable Coronary Artery Disease
Vasospastic Angina Prognosis
- The 5-year survival rate exceeds 90% with treatment.
- Symptoms often persist.
