Cardiology JC006: Chest Pain On Exertion: Ischaemic Heart Disease, Angina Pectoris Flashcards

1
Q

Blood supply to the heart

A
  1. Left coronary artery
    - LAD
    - LCX
  2. Right coronary artery
    - Right marginal
    - Posterior descending
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2
Q

***Pathophysiology of IHD

A

Myocardial ischaemia
1. **Critical coronary stenosis
2. Inflammation
3. Platelets + Coagulation
4. **
Vasospasm
5. ***Microvascular dysfunction
6. Endothelial dysfunction

3 mechanisms leading to mismatch between demand vs supply (can co-exist!!!):
1. Epicardial coronary arteries
- ***Atherosclerotic disease
—> stable plaque / vulnerable plaque —>
—> reduction in CFR (coronary flow reserve)
—> Demand ischaemia +/- stable angina
or
—> plaque rupture leading to thrombosis
—> ACS or infarction

  • ***Vasospastic disease —>
    —> focal/transient vasospasm
    —> Prinzmetal angina
    or
    —> persistent vasospasm
    —> MI
  1. Coronary microcirculation dysfunction (despite patent lumen)
    - ***Microvascular dysfunction
    —> impair coronary physiology + myocardial blood flow
    —> myocardial ischaemia in CAD and CMP + induce severe acute ischaemia “Takotsubo”

Mismatch between demand vs supply
Demand:
- HR
- Wall tension
- Contractility
- Heart hypertrophy

Supply:
- Spasm
- Diastolic time (depend on HR)
- AoP-LVEDP gradient (depend on Ao diastolic pressure + LVEDP)
- Local autoregulation

End result:
Ischaemia
—> **Lactic acidosis + **ST depression + **↓ Contractility + **Pain

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3
Q

Angina pectoris

A

Discomfort in chest / adjacent areas that occur predictably + reproducibly at a certain level of exertion + is relieved with rest / nitroglycerin

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4
Q

Mechanism of Ischaemia chest pain

A

Cardiac pain + neural pathways are poorly understood

Heart do not have its own direct nerve fibre

Angina pectoris:
- results from ischaemic episodes that excite chemosensitive + mechanosensitive receptors in the heart
—> stimulation of the receptors
—> release of **adenosine, **bradykinin, other substance that excite sensory ends of sympathetic + vagal afferent fibres
—> afferent fibres traverse nerves that connect to upper 5 thoracic **sympathetic ganglia + upper 5 distal **thoracic roots of spinal cord
—> within spinal cord, cardiac sympathetic afferent impulse may ***converge with impulses from somatic thoracic structures (i.e. same dermatome)
—> referred cardiac pain

(Silent ischaemia in diabetic patients: related to failed development of cardiac sensory system ∵ reduced nerve growth factor)

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5
Q

Epidemiology of IHD

A
  • number 1 cause of death
  • most common in middle aged, men
  • 60-79 yo: 25% men, 16% women have CHD
  • > 80: 37% men, 23% women
  • presentation of women usually 10 years later than men (60 vs 50 yo)
  • incidence of CHD / angina in post-menopausal women ~ men
  • annual rate of MI in symptomatic angina: 3-3.5% per year
  • within 12 months of initial diagnosis, 10-20% with stable angina progress to unstable angina / MI (if no treatment given)

Initial manifestation:
- Angina pectoris (50%)
- ACS (50%)

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6
Q

Etiologies of IHD

A

Primary cardiac cause
1. **Atherosclerosis (most common)
2. Coronary artery abnormality (spasm / arteritis / dissection / anomalies / radiation-induced)
3. Myocardial bridging
4. **
Aortic stenosis (↑ demand)
5. **Hypertrophic cardiomyopathy (↑ demand)
6. **
Dilated cardiomyopathy
7. ***Tachycardia (↑ demand)

Primary non-cardiac cause
1. **Anaemia
2. Sickle cell disease
3. **
Hypoxaemia
4. CO poisoning
5. Hyperviscosity (e.g. Polycythaemia)
6. **Hyperthyroidism
7. **
Phaeochromocytoma

Risk factors:
1. Smoking —> ↑ BP due to stimulation of chromaffin cells
2. Alcohol —> ↑ BP
3. **High cholesterol
4. **
High BP
5. **Obesity
6. **
Metabolic syndrome
7. ***Type 2 DM
8. Cocaine abuse —> ↑ Sympathetic stimulation —> Vasospasm + ↑ BP + Direct cardiotoxicity (suspect in young patients: acute MI, tachycardia, malignant HT)

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7
Q

Pathogenesis of Atherosclerosis

A

**Atherocyte phagocytise lipid (Fatty streak formation) + **Fibrocyte produce fibrous tissue (+ Ca deposition) + ***Inflammation of wall
—> Pathological intimal thickening with macrophages
—> Fat core (stable: with fibrous cap, unstable: ruptured)
—> Ruptured plaque
—> Platelet + Coagulation activation
—> ACS

2 Factors:
1. **Concentration of lipoprotein
2. **
Susceptibility of arterial walls

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8
Q

***Diagnosis + Assessment of IHD

A
  1. History
    - Clinical risk assessment
    —> Demographics
    —> Risk factors
    —> Stability + Frequency of symptoms
    —> Presence of HF
    —> Prior MI
  • Chest pain symptoms: SOCRATES
    —> Site: retrosternal / slightly to left, occasionally at extrathoracic site
    —> Onset: gradual increase + fading away, usually 2-10 mins
    —> Character: tightness, pressure, squeezing, heaviness, burning, aching, fullness, “heavy weight”, “band across chest”
    —> Radiation: neck throat, lower jaw, **
    left shoulder / arm (ulnar distribution), occasionally to right arm, interscapular, epigastrium, back (
    never below abdomen)
    —> Associations: SOB, dizziness, syncope
    —> Time course: worsening, improving, fluctuating
    —> Exacerbating / Relieving factors: **
    4Es: eating, exertion, emotion, environment vs ***rest, cessation of activity / stress, NTG
    —> Severity: 0-10, may progress from asymptomatic —> pain on exertion —> pain at rest
  • **Non-chest pain symptoms
    —> Dyspnea
    —> Non-chest locations of discomfort (exertional / at rest)
    —> Mid-epigastric / Abdominal
    —> Diaphoresis
    —> Excessive fatigue + weakness
    —> Dizziness + Syncope
  1. P/E (not much to see)
  2. Investigation
    - **Resting ECG (look for previous MI, myocardial ischaemia)
    - Fasting lipid profile + glucose
    - **
    Echocardiogram (look at heart function)
    - ***Exclude potential exacerbating factors e.g. anaemia, thyrotoxicosis
  3. Assessment of myocardial ischaemia (Stress: Exercise to induce ischaemia)
    - **Stress ECG
    - Stress myocardial perfusion scintigraphy
    - **
    Stress Echocardiogram
    - Stress cardiac magnetic perfusion
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9
Q

Non-chest pain symptoms

A
  1. Dyspnea
    - on exertion
    - at rest
    - PND
    - temporal change of ↑ exertional dyspnea with ↓ effort tolerance
  2. Non-chest locations of discomfort (exertional / at rest)
    - neck / mandibular
    - throat tightness
    - shoulder discomfort
    - upper arm / forearm discomfort (more often left side)
    - interscapular / infrascapular
  3. Mid-epigastric / Abdominal
    - mid-epigastric burning, often postprandially
    - sharp abdominal pain (atypical, more in women)
    - RUQ pain (mimic gallbladder disease / pancreatitis)
    - ***N+V (often associated with ↑ vagal tone secondary to inferior MI)
  4. Diaphoresis
  5. Excessive fatigue + weakness
    - discernible prodrome of ↑ fatigue with ↓ effort tolerance
  6. Dizziness + Syncope
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10
Q

***P/E of Chest pain

A
  1. Majority of cases: ***Normal
  2. **Risk factors for CAD
    - BP
    - Weight
    - Lipid abnormalities
    —> **
    corneal arcus
    —> xanthomas
    —> xanthelasma (xanthoma on eyelid)
    - DM
    —> retinal arteriolar changes
    —> ***acanthosis nigricans
    - Tobacco use / COPD
    —> nail stain
    —> prolonged expiration, wheezing, distant breath sounds
    - Frank’s sign (ear lobe crease: potential marker for CAD)
  3. ***Complications of IHD
    - cardiomegaly
    - heart failure
    - MR (functional MR)
    - arrhythmia
    - peripheral arterial disease (PAD)
  4. ***Implicating / contributing conditions for IHD
    - thyrotoxicosis
    - severe anaemia
  5. Other causes of angina / dyspnea
    - AS
    - hypertrophic cardiomyopathy
    - pulmonary HT
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11
Q

***Non-invasive investigations

A
  1. Lipid level
    - ***LDL (very important modifiable risk factor by statin), HDL
    - TG
    - Lipoprotein(a) (lead to inflammation, oxidation of LDL-C) (genetic predisposition, cannot treat)
  2. Metabolic evaluation
    - FG
    - **HbA1c
    - Creatinine
    - **
    Thyroxine
  3. Markers of cardiac function, myocyte injury, ischaemia, haemodynamic stress
    - High-sensitivity CRP (indicate higher risk of inflammation in coronary arteries)
    - **Brain natriuretic peptide (indicate heart failure ∵ IHD)
    - NT-proBNP
    - **
    Troponin T / I (indicate heart injury)
    —> prognostic implications as well
  4. Exercise stress testing (**confirm diagnosis of IHD)
    Indications of stress test: Dx of IHD **
    uncertain
    —> if can exercise + ECG normal —> Treadmill exercise test
    —> if can exercise + ECG abnormal —> Stress Echo, Stress SPECT, MRI, PET
    —> if cannot exercise —> Pharmacological stress test
  • ECG
    —> ST elevation (transmural ischaemia)
    —> ST depression + T inversion (
    subendocardial ischaemia with abnormal repolarisation)
    —> easy to do, easy to interpret, cheap
    —> but limited by abnormality in heart conduction / repolarisation, lower sensitivity / specificity
  • Stress Echo
    —> Regional wall motion abnormality
  • Stress SPECT
  • Cardiac MRI perfusion scan
    —> can also look for scar formation, thinning of wall, ischaemia area (appear white on MRI)
    —> harder to do, harder to interpret, high cost
    —> but higher sensitivity / specificity
  • Pharmacological stress (for patients cannot exercise)
    —> Vasodilator (**Dipyridamole / **Adenosine: coronary vasodilator) —> Steal phenomenon —> ↓ blood flow to ischaemic area —> exaggerate ischaemia —> manifestation on site of ischaemia
    —> Inotrope (
    Dobutamine)
  1. Imaging
    - ***CT coronary angiogram
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12
Q

Flowchart of Non-invasive investigations

A

No chest pain

—> Have CI for stress test / Symptoms warranting coronary imaging
—> ***Coronary imaging (CT / direct)

—> No CI for stress test
—> Symptoms not warrant coronary imaging
—> Able to exercise
—> Resting ECG interpretable / No previous revascularisation —> **Treadmill ECG study
—> Resting ECG not interpretable / previous revascularisation —> **
Stress imaging

—> Not able to exercise —> ***Pharmacological stress imaging study

—> If inadequate information for Dx / prognosis / high risk (if worry to put patient under stress) —> ***Coronary imaging (CT / direct)

簡單而言: Treadmill ECG —> Stress imaging —> Pharmacological stress imaging study —> Coronary imaging (CT / direct)

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13
Q

Invasive investigations

A

Indication:
- unacceptable angina despite medical therapy
- non-invasive test results with high-risk features (e.g. large territory defect)
- angina / risk factors for CAD in setting of depressed LVEF
- for diagnostic purposes, in individual whom results of non-invasive testing are unclear

  1. Coronary angiogram
    - catheter through artery —> inject contrast
    - can be therapeutic
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14
Q

***Management of IHD

A

Treat to target: BP, Lipid, HbA1c

  1. Patient education
  2. Manage comorbid conditions
    - DM, HT, HL
    - use of drugs aggravating angina
    - associated cardiac / non-cardiac diseases
  3. Modify preventable risk factors
    - smoking cessation + moderate alcohol consumption
    - weight reduction
    - regular aerobic exercise
    - diet control (Mediterranean diet: low saturated / trans fat, high polyunsaturated fat, high fish oil, low glycaemic load, high fibre, high folate)
  4. **Pharmacological therapy
    - Lipid lowering drugs (aim LDL-C **
    <1.4)
    - Anti-platelet agents (esp. in secondary prevention)
    - ACEI / ARB (CVD protection)
    - β-blockers (Anti-ischaemic agents)
    - CCB (Anti-ischaemic agents)
    - Nitrates (Anti-ischaemic agents)
    - Ivabradine, Ranolazine, Trimetazidine, Nicorandil (Novel agents)
  5. Revascularisation procedures in selected patients
    - PCI
    - CABG (saphenous ring / internal mammary artery)
    —> if fail medical treatment / uncontrolled
    —> CABG preferable than PCI in:
    —> **Unprotected left main
    —> **
    Severe 3 vessel disease
    —> ***2 vessel disease including a proximal LAD lesion
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15
Q

Lipid lowering drugs

A
  1. ***Statin (↓ LDL-C)
  2. ***Ezetimibe (NPC1L1 inhibitor)
  3. Bile-acid sequestrants (i.e. Resin, poorly tolerated ∵ GI SE)
  4. Mipomersen, Lomitapide (inhibit LDL / VLDL assembly + secretion in liver)
  5. PCSK9 inhibitor Ab (↓ degradation of LDL-R, effective in ↓ LDL-C, non-HDL-C, Lp(a))
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16
Q

Antiplatelet / Anticoagulant

A

↓ Complications of atherosclerosis, plaque rupture, platelet activation

  1. Aspirin
    - in absence of CI
  2. Clopidogrel
    - ADP (P2Y12) receptor antagonist (more potent than Aspirin)
    - if aspirin CI
  3. Aspirin + ADP receptor antagonist (**Dual antiplatelet therapy)
    - **
    after PCI
    - prevent re-stenosis / thrombosis in stent
    - ***6-12 months
  4. Rivaroxaban
    - 2.5mg BD added to low dose aspirin for high risk CAD / PAD patients

SE:
- GI upset (aspirin)
- Bleeding

17
Q

CVD protection: ACEI / ARB

A

Indications:
- ACEI should be prescribed in ***ALL patients with stable IHD
- esp. who have HT, DM, LVEF <=40%, CKD (unless CI)
- ARB for those intolerant to ACEI

SE:
- **Cough (ACEI)
- Syncope
- Postural hypotension
- **
Angioedema (∵ Bradykinin)
- ***HyperK

CI:
- High grade ***bilateral renal artery stenosis

18
Q

β-blockers

A

↓ Contractility, ↓ HR, ↓ wall stress —> ↓ Demand

Indications:
- 1st line monotherapy / in combination with CCB / Nitrates —> prevent angina in patients with CAD
- Systolic LV failure (
EF<40%), HF, prior MI
- Ventricular rate control in AF

SE:
- **Bradycardia
- Syncope
- Hypotension
- **
Bronchial spasm
- ***Impaired glucose tolerance

CI:
- **AV block, sinus node dysfunction
- **
Bronchial asthma
- **Vasospasm angina (i.e. coronary spasm), PAD, **Raynaud phenomenon
- Depression

19
Q

CCB

A

Vasodilator + ↓ HR
- alternative to β-blockers
- less preferable if patient has impaired heart function

Indications:
- Monotherapy / in combination with β-blockers / Nitrates —> prevent angina in patients with CAD
- ***Vasospasm angina
- Ventricular rate control in AF

SE:
- **Bradycardia (non-dihydropyridine CCB)
- Syncope
- Hypotension
- **
Peripheral edema
- Headache
- Dizziness
- Constipation

CI:
- **AV block, **Sinus node dysfunction, ***HF (non-dihydropyridine CCB)

Dihydropyridine (Amlodipine, Nifedipine):
- Vascular dilation
- ↑ HR

Non-dihydropyridine (Diltiazem, Verapamil):
- Myocardial depression (↓ conduction, ↓ HR)
- Negative ionotropic agents —> avoid in HF / ↓ LVEF

20
Q

Nitrates

A

Coronary vasodilation (↓ ischaemia) + Venodilatation (↓ Preload —> ↓ wall stress)

Short-acting nitrates
- relieve acute anginal pain
- prophylactic to improve exercise tolerance + prevent exercise-induced ischaemia

Long-acting nitrates
- monotherapy / in combination with β-blockers / CCB —> prevent angina in patients with CAD

SE:
- Hypotension
- Syncope
- Tachycardia
- **Headache
- **
Facial flushing
- Methaemglobinaemia (less common)

CI:
- HOCM
- Concomitant administration on same day with selective ***PDE-5 inhibitor e.g. Sildenafil, Tadalafil, Vardenafil
- SBP <90 mmHg

21
Q

Novel agents

A

Ivabradine
- **Funny current blocker in SA node —> ↓ HR —> ↓ demand
- no effect on BP
- SE: **
phosphenes, bradycardia, AF, loss of sensation in tongue, dizziness, headache, uncontrolled BP, ventricular extrasystoles, 1st degree AV block

Ranolazine
- Unknown mechanism (Late Na channel blocker) —> ↓ Ca overload —> ↓ wall stress
- SE: ***prolong QT, nausea, headache, dizziness, constipation, syncope, postural hypotension
- CI: liver / renal failure

Trimetazidine:
- Blockade of acyl-CoA β-oxidation —> improve energy use
- SE: N+V, fatigue, dizziness, myalgia, induce parkinsonian symptoms

Nicorandil:
- **Activation of ATP-sensitive K channel —> dilation of coronary artery
+
- **
Nitrate-associated effects —> dilation of coronary artery
- SE: caution in patients taking corticosteroids due to small risk of GI perforation
- sulfonylurea may antagonise effects of nicorandil

22
Q

Use of Anti-ischaemic agents

A

β-blocker
—> CCB / Nitrates
—> Ivabradine / Ranolazine / Nicorandil

23
Q

***Overview of management

A

***Angina relief:
1. β-blockers
2. CCB
3. Nitrates
4. Ivabradine / Nicorandil / Ranolazine / Trimetazidine

***Prognosis improvement:
1. Lipid lowering drugs
2. Antiplatelet / Anticoagulant
3. RAAS inhibitors
4. Anti-inflammatory?

Silent ischaemia
- β-blockers
- CCB

24
Q

Angina with evidence of MI / Non-obstructive CAD

A

Cardiac syndrome X (due to **small vessel disease / coronary spasm)
- Traditional pharmacological antianginal, anti-ischaemic medications
- Enhanced external counterpulsation
- **
CBT, ***Tricyclic medication, Neurostimulation

25
Q

Congenital Coronary Anomalies

A
  • 6-17% of sudden death in athletes

Symptoms:
- Chest pain
- Exertional syncope
- Sudden cardiac death

P/E + ECG:
- NAD

Diagnosis:
- ***CT coronary angiogram
- MRI
- Coronary angiogram

Management:
- Avoid competitive sport
- Consider ***surgical intervention if +ve for myocardial ischaemia

26
Q

Prinzmetal variant

A

**Coronary spasm with / without superimposed CAD
- Occurs at rest, common after **
cold exposure
- **Cyclical in nature
- ECG finding of **
episodic ST elevation
- patients more likely to develop ventricular arrhythmia

Treatment:
- CCB +/- Nitrates
- ***NOT use β-blockers (∵ induce coronary spasm)!!!

27
Q

Summary

A

ABCDE for IHD

A:
- Antiplatelet
- Anti-anginal (Nitrate, Ivabradine, Ranolazine, Nicorandil)
- ACEI / ARB
- Angioplasty

B:
- β-blockers
- BP control
- Bypass

C:
- Cholesterol lowering agents
- CCB
- Cigarette cessation

D:
- DM management
- Diet

E:
- Education
- Exercise