Case 6 Flashcards
What causes stable angina pectoris?
Transiet myocardial ischemia
Angina is more common in who?
more common: males less than 50 years old
in women its atypical
what types of pain does a person feel in Angina?
heaviness, pressure, squeezing, smothering, or choking
How does a patient show u where the pain is if they’re suffering from angina?
they place their hand on the sternum with a clenched fist (LEVINE’S SIGN)
where does Angina typically radiate to?
shoulder and ulnar surfaces of forearm and hand, as well as the back, inter scapular region, root of neck, jaw, teeth, and epigastrium
How long does a stable Angina usually last?
2 - 5 mins (Crescendo-decrescendo)
How can u differentiate if the pain is caused by myocardial ischemia or something else?
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.
What disease is indicated by pain radiation to Trapezius?
pericarditis
what causes typical angina? and how is it relieved?
exertion (exercise, sexual activity, emotion, hurrying)
relieved by rest
what type of angina is caused while the person is resting and recumbent?
Angina Decubitus
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?
Nocturnal Angina
in Nocturnal angina, what does recumbency lead to?
increase in cardiac size due to expansion of intrathoracic blood volume (end diastolic volume)
What are causes of nocturnal angina?
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
How do u know if a patient has a stable exertional angina?
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
What causes a variation is the threshold of angina in some patients?
changes in coronary vasomotor tone
An elderly diabetic patient presents with dyspnea, nausea, fatigue, and faintness. What is your diagnosis?
myocardial ischemia
Why should we examine an angina patient for peripheral arterial diseases? and what could we find?
1- to uncover an unstable syndrome associated with increased risk.
2- presence of coronary atherosclerosis, stroke, or transient ischemic attacks
What are risk factor we may find in a patient’s family history?
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
What may be the reason behind persistent ischemic-type chest discomfort in women without flow-limiting obstructions?
1- microvascular coronary disease
2- abnormal cardiac nociception
How can we confirm that a patient has microvascular coronary disease?
1- by responding to vasoactive agents (intracoronary adenosine, acetylcholine, nitroglycerin)
How can we treat microvascular coronary disease and cardiac nociception?
1- improving endothelial function (by nitrates, beta blockers, calcium antagonists, statins, ACE inhibitors)
2- imipramine for nociception
In a physical examination, what should clinicians search for?
1- abdominal aortic aneurysm
2- carotid arterial bruits
3- diminished arterial pulses in lower extremities
What are evidence for risk factors of atherosclerosis?
1- xanthelasmas & xanthomas
2- protuberant abdomen caused by metabolic syndrome
How do we find evidence of peripheral arterial disease?
evaluating the pulse control (ankle-brachial index)
What other systemic evidence can we find that could suggest peripheral arterial disease?
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
Palpation of a patient with Angina may show what?
1- cardiac enlargement
2- left ventricular dyskinesia
Auscultation of a patient suffering from Angina in a left lateral decubitus position may show what?
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)
What may cause angina if coronary atherosclerosis is absent?
1- aortic stenosis
2- aortic regurgitation
3- pulmonary hypertension
4- hypertrophic cardiomyopathy
What may be found if you are examining a patient currently suffering from an anginal attack?
transient left ventricular failure leading to 1- third and fourth heart sounds 2- dyskinetic cardiac apex 3- mitral regurgitation 4- pulmonary edema
What lab examinations can we use to help in the diagnosis of Angina?
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
What can we find on an ECG that indicates increased risk of adverse outcomes from IHD?
left ventricular hypertrophy
What causes Prinzmetal’s variant angina?
focal spasm of epicardial coronary artery
What is the reason behind the focal spasm in PVA?
hyper contractility of vascular smooth muscles due to adrenergic vasoconstrictors, leukotrienes or serotonin
How can we diagnose PVA?
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
what is the diagnostic hallmark of PVA?
transient coronary spasm
how do we provoke focal coronary stenosis or rest angina with ST-segment elevation for diagnosis?
hyperventilation or intracoronary acetylcholine
if there is an atherosclerotic plaque in a proximal coronary artery, where will the spasm occur?
within 1 cm of the plaque
where are focal spasms more common?
right coronary artery
