Chronic coronary syndromes

Question 1

what is angina?

Answer 1

mismatch of oxygen demand and supply

Question 2

what is the most comments reason of angina ?

Answer 2

IHD

Question 3

what are the risk factors for IHD?

Answer 3

Age
Cigarette smoking
Family history
Diabetes mellitus
Hyperlipidemia
Hypertension
Kidney disease
Obesity
Physical inactivity
Stress

Question 4

what factors effect the supply ?

Answer 4

Anemia
Hypoxemia
Polycythemia
Hypothermia
Hypovolaemia
Hypervolaemia

Question 5

what factors effect the demand?

Answer 5

Hypertension
Tachyarrhythmia
Valvular heart disease
Hyperthyroidism
Hypertrophic cardiomyopathy

Question 6

what environmental effect/ increase angina?

Answer 6

cold weather
heavy meals
emotional stress

Question 7

when does myocardial ischemia occur?

Answer 7

when there is an imbalance between the heart’s oxygen demand and supply, usually from an increase in demand (eg exercise) accompanied by limitation of supply

Question 8

what are the three factors limit supply? ( good thing)

Answer 8

1. Impairment of blood flow by proximal arterial stenosis
2. Increased distal resistance eg left ventricular hypertrophy
3. Reduced oxygen-carrying capacity of blood eg anemia

Question 9

what is ohms law?

Answer 9

V = IR
So, in biology:
ΔP = QR

Question 10

what other anginas are there?

Answer 10

Prinzmetal’s angina (coronary spasm)
Microvascular angina (Syndrome X)
Crescendo angina
Unstable angina

Question 11

what thins would you have to ask when taking a history? ( IHD)

Answer 11

Personal details (demographics, identifiers)
Presenting complaint
History of PC + risk factors
Past medical history
Drug history, allergies
Family history
Social history
Systematic enquiry

Question 12

what are cardiac symptoms?

Answer 12

Chest pain (tightness/ discomfort)
Breathlessness
Fluid retention
Palpitation
Syncope or pre-syncope

Question 13

How to find out what sort of pain it is, questions to think about?

Answer 13

O-nset
P-osition (site)
Q-uality (nature / character)
R-elationship (with exertion, posture, meals, breathing and with other symptoms)
R-adiation
R-elieving or aggravating factors
S-everity
T-iming
T-reatment

( OPQRST)

Question 14

what are the differential diagnoses of myocardial ischemia?

Answer 14

Pericarditis/ myocarditis
Pulmonary embolism/ pleurisy
Chest infection/ pleurisy
Dissection of the aorta
Gastro-oesophageal (reflux, spasm, ulceration)
Musculo-skeletal
Psychological

Question 15

what treatments are given for angina ?

Answer 15

Reassure
Change lifestyle
-smoking
-Weight
-Exercise
-diet
Advice for emergency
Medication
Revascularisation

Question 16

what investigations would you do when suspecting angina?

Answer 16

Routine bloods, lipids, ECG

Question 17

what are the possible treatment options for angina?

Answer 17

Smoking, Aspirin, B blocker, statin, GTN

Question 18

what are the different diagnostic tests that are done the unsuspecting angina and when would you do them?

Answer 18

CT Cor Angio - if Typical or atypical
Other non-inv- if Known CHD and uncertain history
Cor Angio- If non invasive inconclusive or very high risk

Question 19

what are the effects of beta blockers on the heart?

Answer 19

• decreases HR ( -ve chronotropic)
• decreases Contractility ( -ve inotropic)
• decreases CO
• decreases 02 demand

Question 20

what are the side effects of beta blockers?

Answer 20

-tiredness
-nightmares
-erectile dysfunction
-cold hands, feet
-bradycardia

Question 21

what are the relative contraindications of beta blockers?

Answer 21

-verapamil
-diltiazem
-amiodarone
-caution- digoxin

Question 22

what are nitrates?

Answer 22

ventilators

Question 23

what do ca2+ channel blockers do?

Answer 23

• -ve inotropic- LV contraction decreases
  cause- flushing, postural hypotension, swollen ankles

Question 24

who do you not give a beta blocker to?

Answer 24

someone with severe asthma -severe bronchospasms

Question 25

name a anti platelet agent?

Answer 25

aspirin

Question 26

what does aspirin inhibit?

Answer 26

Cyclo-oxygenase inhibitor

Question 27

what does aspirin do?

Answer 27

↓ prostaglandin synthesis, incl. thromboxane
↓ platelet aggregation, antipyretic, anti-inflammatory, analgesic

Question 28

what should you be cautious about with aspirin?

Answer 28

gastric ulceration

Question 29

who are ACE inhibitors given to?

Answer 29

Given to patients
With IHD and
HBP or DM

Question 30

what is PCI?

Answer 30

stenting
(Percutaneous coronary intervention )
All done under x ray control

Question 31

what are the pros of PCIs?

Answer 31

Less invasive
Convenient
Repeatable
Acceptable

Question 32

what are the cons of PCI?

Answer 32

Risk stent thrombosis
Risk restenosis
Can’t deal with complex disease
Dual antiplatelet therapy

Question 33

What is CABG?

Answer 33

A coronary artery bypass graft s a surgical procedure used to treat coronary heart disease.
It diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart.

Question 34

what are the pros of CABG?

Answer 34

Prognosis- durable
Deals with complex disease

Question 35

what are the cons of CABG?

Answer 35

Invasive
Risk of stroke, bleeding
Can’t do if frail, comorbidities
One time treatment
Length of stay
Time for recovery

Question 36

describe the treadmill test

Answer 36

Induce ischaemia while walking uphill, incrementally fast
Look for ST segment depression
Detects a ‘large stage’ of ischaemia
Many patients unsuitable
Can’t walk
Very unfit
Young females
No longer on the UK NICE guidelines

Question 37

investigations of angina

Answer 37

12 lead ECG
Often normal – no direct markers of angina
Signs of IHD: Q waves, T-wave inversion, BBB
Echocardiogram
Normal – no direct markers of angina
Signs of previous infarcts/ alternative diagnoses
To check LV function
Anatomical/physiological tests, invasive/ non-invasive:
Anatomical
CT angiography
High NPV
Low PPV
Ideal for excluding CAD in younger, low risk individuals
Invasive angiography
Purely anatomical but some modern functional testing techniques
Physiological (all non-invasive)
Exercise stress treadmill
Stress echo
Perfusion (stress) MRI