Chronic Stable Angina Pectoris Flashcards
Define Stable Angina
Episodic pain caused by increased myocardial demand due to impaired perfusion
How much of an artery must be stenosed to cause angina?
> 70% of a main coronary artery
What precipitants are there of Angina?
Exercise
Emotion
Cold
Heavy meals
What symptoms are associated with Angina?
Dysponea
Nausea
Sweatiness
Faintness
What are the common causes of Angina?
ATHEROMA - CAD
Valvular heart disease
Cardiomyopathy
Anaemia
What are the risk factors for Angina?
Smoking Obesity Hypertensive DM Raised cholesterol Prev MI Family history of CVD
Describe how CAD leads to Angina
CAD - coronary artery disease, thickening of arterial walls due to presence of atherosclerosis
Restricts passage of blood - hypoxia
Exacerbated on exertion
Describe how valvular heart disease leads to Angina
Aortic stenosis/regurgitation often lead to heart failure
Cause Left Ventricle Hypertrophy
Increased muscle mass but no increase in supply - angina
Describe how cardiomyopathy leads to Angina
Most commonly hypertrophic cardiomyopathy (HCM)
Increased muscle mass but no increase in supply - angina
Describe how anaemia leads to Angina
Lowered Hb/RBC in blood ie. reduced oxygen carrying capacity
Reduced Ox in blood - reduced Ox to heart - angina
What is Xanthelasmata?
Deposits of fat s.c. around eyes/nails
Sign of excess cholesterol
Suggestive of poss atheroma?
What is Tendon Xanthoma?
Papules/nodules of fat in tendons of hands/feet/heel
Sign of excess cholesterol (familial hypercholesterolaemia)
How is Hypertension related to Angina?
High BP causes damage to coronary arteries
Also increased requirements of heart to pump against raised BP
How is Hyperthyroidism related to Angina?
Hyperthyroidism causes
-tachycardia (can lead to AF)
-systolic hypertension
Both can lead to angina
What is Arteriosclerosis?
Non-specific thickening and hardening of arterial walls causing a loss of contractility/elasticity and decreased blood flow
Often due to prolonged HTN in smaller arteries
What is Atheroma?
Specific degenerative disease affecting large/medium size arteries
What is Atherosclerosis?
Thickening/hardening of arterial walls due to atheroma
Reduces tissue perfusion
Predisposes to thrombus/aneurysm formation
Describe the pathology of atheroma formation
Damage to endothelium allows LDLs to enter intima
Lipid taken up by macrophages –> FATTY STREAK
Macrophages release lipid into intima & stimulate cytokines –> collagen deposition –> FIBROTIC LIPID PLAQUE
Fibrotic plaque leads to atrophy of media/lamina –> fragile endothelium –> ULCERATION
What is the appearance of the initial fibrotic lipid plaque?
Raised
Yellow
What is the appearance of the late stage fibrotic lipid plaque?
Hard
White
How would a patient with suspected angina be investigated?
ECG - often normal, may show -ST depression, flat/inverted T waves (prev MI) Angiography Functional imaging Coronary Artery Calcification Score
What drugs are used to treat Angina?
Aspirin B-blockers Nitrates - i.e. GTN spray Calcium channel blockers K+ channel activators - i.e. nicorandil
How does Aspirin work?
Antiplatelet agent - limits thrombosis - decreased obstruction
Pain relief
What are the common side effects of Aspirin?
Gastric damage (ie. ulcers)
Dyspepsia
Nausea/Vomiting
How do B-blockers work?
-ve inotropic/chronotropic effects
Anti-arrhythmic effects
More time in diastole - increased coronary flow
What are the common side effects of B-blockers?
Bronchospasm
Reduced hypoglycaemic awareness
Fatigue
Cardiac depression/bradycardia
How do Nitrates work?
Release NO
Cause venodilation - decreased preload/cardiac work
Coronary vasodilatation
What are the common side effects of Nitrates?
Headaches Flushing Burning under the tongue Postural hypotension Dizziness
How do Calcium Channel Blockers work?
Antagonise Calcium channels - hyperpolarisation
Vasodilatation
Verapamil also bradycardic/myocardial depressant/anti-arrhythmic
What are the common side effects of Calcium Channel Blockers?
Flushing
Headaches
Peripheral oedema
Constipation
How do K+ channel activators work?
Katp channel activated - hyperpolarisation
Vasodilatation & reduced work
What are the common side effects of K+ channel activators?
Headaches Nausea/vomiting Flushing Dizziness Abdominal pain Ulcers
What are the two common variants of stable angina?
Decubitus
Prinzmetal’s (variant)
What is Decubitus angina?
Angina precipitated by lying down
Due to increased venous return
Associated w/ LVF
What is Prinzmetal’s angina?
Occurs at rest
Due to coronary artery spasm
What are the non-pharmacological treatment options for angina?
Angioplasty (PCTA)
Coronary Artery Bypass Grafting (CABG)
Describe angioplasty (PTCA)
Percutaneous transluminal coronary angioplasty
Dilates coronary obstructions by inflating a catheter mounted balloon
Uses fluroscopy
What are the risks of PTCA?
Local dissection of coronary artery
Acute coronary occlusion
1% mortality, 2% AMI
What are the long term impacts of PTCA?
Improves sx
No prognostic benefit
Requires aspirin/clopidgorel
Describe CABG
Replacement of diseased artery with healthy artery from elsewhere
What are the indications for CABG?
Sx control for patients unsuitable for PCI
Patients w/ 3 vessel CAD
What are the employment/driving limitations of ACS?
Work –> Office after 2mo, certain occupations should not return to work
Travel –> Avoid air travel for 2mo
Sex –> Avoid intercourse for 1mo
Driving –> DVLA not notified, start after 1-4wks
What are the employment/driving limitations of angina?
DVLA not notified
Driving can continue unless angina occurs at rest, whilst driving or w/ emotion
What are the employment/driving limitations of AAA?
Notify DVLA if >6cm
Annual review, license revoked if >6.5cm
How do ACS/cardiac diagnoses affect HGV drivers?
Revoked license for 6weeks-3mo
Re-licensing at a later date
