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2a- Cardiology > Chronic coronary syndromes/ stable angina > Flashcards

Chronic coronary syndromes/ stable angina Flashcards

1
Q

What is angina?

A
  • Angina is a symptom which occurs as a consequence of restricted coronary blood flow and is
    almost exclusively secondary to atherosclerosis
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2
Q

What is the physiology of angina?

A
  • O2 supply demand mismatch + limitation of supply:
    1. Impairment of blood flow by proximal arterial stenosis
    2. Increased distal resistance e.g. left ventricular hypertrophy
    3. Reduced oxygen-carrying capacity of blood e.g. anaemia
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3
Q

Describe what occurs in Electro-hydraulic analogy: healthy rest

A
  • In the healthy system, the resistance of the epicardial artery is negligible and so the flow
    through the system is determined by the resistance of the microvascular vessels
  • Total flow is around 3ml/s
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4
Q

Describe what occurs in Electro-hydraulic analogy: healthy exercise

A
  • Under exercise conditions more flow is needed to meet metabolic demand
  • The microvascular resistance falls so that flow can increase
  • Total flow can increase up to around fivefold (15ml/s)
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5
Q

Describe what occurs in Electro-hydraulic analogy: diseased rest

A
  • Epicardial disease causes the resistance of the epicardial vessel to increase
  • To compensate, the microvascular resistance reduces in order to maintain flow at 3ml/s
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6
Q

Describe what occurs in Electro-hydraulic analogy: diseased exercise

A
  • Epicardial resistance is high due to the stenosis
  • During exercise the microvascular
    resistance falls and increase flow
  • However, there comes a point where minimising microvascular resistance is maxed out and can fall no more – flow cannot meet metabolic demand
  • The myocardium becomes ischaemic and pain is typically experienced
  • The only way to reverse this is to rest, thus reducing the demand for flow
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7
Q

What are the non-modifiable risk factors of angina?

A
  • Age
  • Gender
  • Family history
  • Personal history
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8
Q

What are the modifiable risk factors of angina?

A
  • Smoking
  • Diabetes
  • Hypertension
  • Hypercholesterolaemia
  • Sedentary lifestyle
  • Stress
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9
Q

What are exacerbating factors that decrease the supply for angina?

A
  • Anemia
  • Hypoxemia
  • Polycythemia
  • Hypothermia
  • Hypovolaemia
  • Hypervolaemia
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10
Q

What are exacerbating factors that increase the demand for angina?

A
  • Hypertension
  • Tachyarrhythmia
  • Valvular heart disease
  • Hyperthyroidism
  • Hypertrophic cardiomyopathy
  • Cold weather
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11
Q

What are other anginas?

A
  • Prinzmetal’s angina (coronary spasm)
  • Microvascular angina (Syndrome X)
  • Crescendo angina
  • Unstable angina
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12
Q

What is seen in the presentation history for angina?

A
  • Chest pain/discomfort
    1. Heavy, central, tight, radiation to arms, jaw, neck
    2. Precipitated by exertion
    3. Relieved by rest/ GTN spray
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13
Q

What is the scoring system for diagnosing angina?

A
  • All worth one mark each in the scoring system:
    3/3 = typical angina
    2/3 = atypical angina
    ≤1/3 = non-anginal pain
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14
Q

What are cardiac symptoms of angina?

A
  • Chest pain (tightness/ discomfort)***
  • Breathlessness **
  • Fluid retention
  • Palpitation
  • Syncope or pre-syncope
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15
Q

What is the differential diagnosis for chest pain?

A
  • Myocardial ischemia*
  • Pericarditis/ myocarditis
  • Pulmonary embolism/ pleurisy
  • Chest infection/ pleurisy
  • Dissection of the aorta
  • Gastro-oesophageal (reflux, spasm, ulceration)
  • Musculo-skeletal
  • Psychological
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16
Q

What is the presentation in examination for angina?

A
  • Often normal/ near normal
  • Signs of risk factors:
    o Smoking
    o Hypercholesterolaemia
    o Diabetes
    o Hypertension
  • Signs of complications e.g. scars (pacemakers etc.)
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17
Q

What are investigations for angina?

A
  • 12 lead ECG
  • Echocardiogram
  • Anatomical investigations
  • Physiological investigations
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18
Q

What does an ECG show for angina?

A
  • Often normal – no direct markers of angina
  • Signs of IHD: Q waves, T-wave inversion, BBB
19
Q

What does an echocardiogram show for angina?

A
  • Normal – no direct markers of angina
  • Signs of previous infarcts/ alternative diagnoses
  • To check LV function
20
Q

What are anatomical investigations for angina?

A
  • CT angiography
    • High NPV
    • Low PPV
    • Ideal for excluding CAD in
      younger, low risk individuals
  • Invasive angiography
21
Q

What are physiological investigations for angina?

A
  • Exercise stress treadmill
  • Stress echo
  • Perfusion (stress) MRI
22
Q

What is the treadmill test?

A
  • 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
23
Q

What is primary prevention for angina?

A
  • Reducing the risk of CAD and complications
  • Risk factor modification
24
Q

What is secondary prevention for angina?

A
  • Risk factor modification
  • Symptomatic therapy vs prognostic therapy
25
Q

What is the order of intervention for angina?

A
  1. Lifestyle changes
    - Risk factor and behaviour modification
    - Akin to primary prevention
  2. Pharmacological
    - To reduce cardiovascular events
    - To reduce symptoms
  3. Interventional (PCI and sometimes surgery)
    - To reduce events
    - To reduce symptoms
26
Q

What are the 1st line antianginals?

A
  • Betablockers
  • Nitrates
  • Calcium channel antagonists
27
Q

What do betablockers act on for angina?

A

Beta 1 specific

28
Q

What are the effects of betablockers on the heart?

A
  • Antagonise sympathetic nervous activation
  • (Decreases HR, decreases contractility)
  • Therefore reduce work of heart (CO) and O2 demand
29
Q

What are the contraindications of beta blockers?

A
  • Don’t give to someone with severe asthma
    • Cause bronchospasm
30
Q

What do nitrates act on?

A
  • Primary venodilators
  • Dilate systemic veins
  • Reduce preload on the heart
  • Therefore (Frank-S mechanism) reduce work of heart and O2 demand
31
Q

What do calcium channel antagonists act on?

A
  • Primary arterodilators
  • Dilate systemic arteries
  • Reduce afterload on the heart
  • Reduce energy required to produce same cardiac output – reduce work of heart and oxygen demand
32
Q

What’s an antiplatelet agent that can be used to treat angina?

A

Aspirin

33
Q

What are other drugs that can be used to treat angina?

A

Statins
ACE inhibitors

34
Q

What do statins do?

A
  • Reduce events
  • Reduce LDL-cholesterol
  • Anti-atherosclerotic but other mechanisms of action proposed
35
Q

Which treatments would be given at the GP?

A
  • Aspirin
  • GTN
  • β Blocker
  • Statin
36
Q

Which treatments would be given in hospital?

A
  • CTCA/ functional test of ischaemia
  • ACE inhibitor
  • Long acting nitrate
  • Revascularisation: PCI / CABG: MDT meeting
  • Ca++ channel blocker
  • Potassium channel opener
  • Ivabradine
36
Q

What is revascularisation?

A
  • To restore patent coronary artery and increase flow reserve
  • Either when medication fails or when high risk disease identified
37
Q

What is PCI?

A
  • Percutaneous coronary intervention (PCI- stenting)
38
Q

What is CABG?

A

Coronary artery bypass graft
(CABG) surgery

39
Q

What are the pros of PCI?

A

Less invasive
Convenient
Repeatable
Acceptable

40
Q

What are the cons of PCI?

A

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

41
Q

What are the pros of CABG?

A

Better prognosis
Deals with complex disease

42
Q

What are the cons of CABG?

A

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

43
Q

What are the complications of angina?

A
  • ACS (acute coronary syndrome) – stable becoming unstable
  • CCF – coronary-cameral fistula
  • Conduction disease
  • Arrhythmia

2a- Cardiology (7 decks)

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