Case 6

Question 1

What causes stable angina pectoris?

Answer 1

Transiet myocardial ischemia

Question 2

Angina is more common in who?

Answer 2

more common: males less than 50 years old

in women its atypical

Question 3

what types of pain does a person feel in Angina?

Answer 3

heaviness, pressure, squeezing, smothering, or choking

Question 4

How does a patient show u where the pain is if they’re suffering from angina?

Answer 4

they place their hand on the sternum with a clenched fist (LEVINE’S SIGN)

Question 5

where does Angina typically radiate to?

Answer 5

shoulder and ulnar surfaces of forearm and hand, as well as the back, inter scapular region, root of neck, jaw, teeth, and epigastrium

Question 6

How long does a stable Angina usually last?

Answer 6

2 - 5 mins (Crescendo-decrescendo)

Question 7

How can u differentiate if the pain is caused by myocardial ischemia or something else?

Answer 7

myocardial ischemia does not radiate to the trapezius, and does not cause a sharp fleeting chest pain or a prolonged dull ache in the left submammary area.

Question 8

What disease is indicated by pain radiation to Trapezius?

Answer 8

pericarditis

Question 9

what causes typical angina? and how is it relieved?

Answer 9

exertion (exercise, sexual activity, emotion, hurrying)

relieved by rest

Question 10

what type of angina is caused while the person is resting and recumbent?

Answer 10

Angina Decubitus

Question 11

A patient is awakened with typical chest discomfort and dyspnea. Investigations showed episodic tachycardia, diminished oxygenation, with an expansion of intrathoracic blood volume. What is your diagnosis?

Answer 11

Nocturnal Angina

Question 12

in Nocturnal angina, what does recumbency lead to?

Answer 12

increase in cardiac size due to expansion of intrathoracic blood volume (end diastolic volume)

Question 13

What are causes of nocturnal angina?

Answer 13

1- episodic tachycardia
2- respiratory pattern changes during sleep
3- expansion of intrathoracic blood volume
4- wall tension
5- myocardial oxygen demand
6- transient left ventricle failure

Question 14

How do u know if a patient has a stable exertional angina?

Answer 14

they know they have a fixed threshold that causes it, so coronary stenosis and myocardial oxygen supply are fixed. So Its precipitated by an increased oxygen demand

Question 15

What causes a variation is the threshold of angina in some patients?

Answer 15

changes in coronary vasomotor tone

Question 16

An elderly diabetic patient presents with dyspnea, nausea, fatigue, and faintness. What is your diagnosis?

Answer 16

myocardial ischemia

Question 17

Why should we examine an angina patient for peripheral arterial diseases? and what could we find?

Answer 17

1- to uncover an unstable syndrome associated with increased risk.
2- presence of coronary atherosclerosis, stroke, or transient ischemic attacks

Question 18

What are risk factor we may find in a patient’s family history?

Answer 18

in a <55 year old male and <65 year old female first-degree relative we may find 
1- diabetes 
2- hyperlipidemia 
3- hypertension 
4- cigarette smoking

Question 19

What may be the reason behind persistent ischemic-type chest discomfort in women without flow-limiting obstructions?

Answer 19

1- microvascular coronary disease

2- abnormal cardiac nociception

Question 20

How can we confirm that a patient has microvascular coronary disease?

Answer 20

1- by responding to vasoactive agents (intracoronary adenosine, acetylcholine, nitroglycerin)

Question 21

How can we treat microvascular coronary disease and cardiac nociception?

Answer 21

1- improving endothelial function (by nitrates, beta blockers, calcium antagonists, statins, ACE inhibitors)
2- imipramine for nociception

Question 22

In a physical examination, what should clinicians search for?

Answer 22

1- abdominal aortic aneurysm
2- carotid arterial bruits
3- diminished arterial pulses in lower extremities

Question 23

What are evidence for risk factors of atherosclerosis?

Answer 23

1- xanthelasmas & xanthomas

2- protuberant abdomen caused by metabolic syndrome

Question 24

How do we find evidence of peripheral arterial disease?

Answer 24

evaluating the pulse control (ankle-brachial index)

Question 25

What other systemic evidence can we find that could suggest peripheral arterial disease?

Answer 25

1- Fundi may reveal increased light reflex and arteriovenous nicking (caused by hypertension)
2- anemia
3- thyroid disease
4- nicotine stains in fingertips indicating smoking

Question 26

Palpation of a patient with Angina may show what?

Answer 26

1- cardiac enlargement

2- left ventricular dyskinesia

Question 27

Auscultation of a patient suffering from Angina in a left lateral decubitus position may show what?

Answer 27

1- arterial bruits
2- third or/and fourth heart sounds
3- apical systolic murmur due to mitral regurgitation (caused by acute ischemia or previous infarction impairing papillary muscles)

Question 28

What may cause angina if coronary atherosclerosis is absent?

Answer 28

1- aortic stenosis
2- aortic regurgitation
3- pulmonary hypertension
4- hypertrophic cardiomyopathy

Question 29

What may be found if you are examining a patient currently suffering from an anginal attack?

Answer 29

transient left ventricular failure leading to 
1- third and fourth heart sounds 
2- dyskinetic cardiac apex 
3- mitral regurgitation 
4- pulmonary edema

Question 30

What lab examinations can we use to help in the diagnosis of Angina?

Answer 30

1- Urine: evidence of diabetes and renal disease (microalbuminuria)
2- blood: measure lipids, glucose (hemoglobin A1C), creatinine, hematocrit, thyroid function
3- Chest x-ray: cardiac enlargement, ventricular aneurysm, signs of heart failure
4- CRP (between 0 and 3mg) to reclassify the risk of IHD

Question 31

What can we find on an ECG that indicates increased risk of adverse outcomes from IHD?

Answer 31

left ventricular hypertrophy

Question 32

What causes Prinzmetal’s variant angina?

Answer 32

focal spasm of epicardial coronary artery

Question 33

What is the reason behind the focal spasm in PVA?

Answer 33

hyper contractility of vascular smooth muscles due to adrenergic vasoconstrictors, leukotrienes or serotonin

Question 34

How can we diagnose PVA?

Answer 34

1- transient ST-segment elevation with rest pain
2- episodes of asymptomatic ST-segment elevations (silent ischemia)
3- small elevations of troponin in prolonged attacks

Question 35

what is the diagnostic hallmark of PVA?

Answer 35

transient coronary spasm

Question 36

how do we provoke focal coronary stenosis or rest angina with ST-segment elevation for diagnosis?

Answer 36

hyperventilation or intracoronary acetylcholine

Question 37

if there is an atherosclerotic plaque in a proximal coronary artery, where will the spasm occur?

Answer 37

within 1 cm of the plaque

Question 38

where are focal spasms more common?

Answer 38

right coronary artery