Chronic Stable Angina Pectoris

Question 1

Define Stable Angina

Answer 1

Episodic pain caused by increased myocardial demand due to impaired perfusion

Question 2

How much of an artery must be stenosed to cause angina?

Answer 2

> 70% of a main coronary artery

Question 3

What precipitants are there of Angina?

Answer 3

Exercise
Emotion
Cold
Heavy meals

Question 4

What symptoms are associated with Angina?

Answer 4

Dysponea
Nausea
Sweatiness
Faintness

Question 5

What are the common causes of Angina?

Answer 5

ATHEROMA - CAD
Valvular heart disease
Cardiomyopathy
Anaemia

Question 6

What are the risk factors for Angina?

Answer 6

Smoking
Obesity
Hypertensive
DM
Raised cholesterol
Prev MI
Family history of CVD

Question 7

Describe how CAD leads to Angina

Answer 7

CAD - coronary artery disease, thickening of arterial walls due to presence of atherosclerosis
Restricts passage of blood - hypoxia
Exacerbated on exertion

Question 8

Describe how valvular heart disease leads to Angina

Answer 8

Aortic stenosis/regurgitation often lead to heart failure
Cause Left Ventricle Hypertrophy
Increased muscle mass but no increase in supply - angina

Question 9

Describe how cardiomyopathy leads to Angina

Answer 9

Most commonly hypertrophic cardiomyopathy (HCM)

Increased muscle mass but no increase in supply - angina

Question 10

Describe how anaemia leads to Angina

Answer 10

Lowered Hb/RBC in blood ie. reduced oxygen carrying capacity

Reduced Ox in blood - reduced Ox to heart - angina

Question 11

What is Xanthelasmata?

Answer 11

Deposits of fat s.c. around eyes/nails
Sign of excess cholesterol
Suggestive of poss atheroma?

Question 12

What is Tendon Xanthoma?

Answer 12

Papules/nodules of fat in tendons of hands/feet/heel

Sign of excess cholesterol (familial hypercholesterolaemia)

Question 13

How is Hypertension related to Angina?

Answer 13

High BP causes damage to coronary arteries

Also increased requirements of heart to pump against raised BP

Question 14

How is Hyperthyroidism related to Angina?

Answer 14

Hyperthyroidism causes
-tachycardia (can lead to AF)
-systolic hypertension
Both can lead to angina

Question 15

What is Arteriosclerosis?

Answer 15

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

Question 16

What is Atheroma?

Answer 16

Specific degenerative disease affecting large/medium size arteries

Question 17

What is Atherosclerosis?

Answer 17

Thickening/hardening of arterial walls due to atheroma
Reduces tissue perfusion
Predisposes to thrombus/aneurysm formation

Question 18

Describe the pathology of atheroma formation

Answer 18

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

Question 19

What is the appearance of the initial fibrotic lipid plaque?

Answer 19

Raised

Yellow

Question 20

What is the appearance of the late stage fibrotic lipid plaque?

Answer 20

Hard

White

Question 21

How would a patient with suspected angina be investigated?

Answer 21

ECG - often normal, may show
-ST depression, flat/inverted T waves (prev MI)
Angiography
Functional imaging
Coronary Artery Calcification Score

Question 22

What drugs are used to treat Angina?

Answer 22

Aspirin
B-blockers
Nitrates - i.e. GTN spray
Calcium channel blockers
K+ channel activators - i.e. nicorandil

Question 23

How does Aspirin work?

Answer 23

Antiplatelet agent - limits thrombosis - decreased obstruction
Pain relief

Question 24

What are the common side effects of Aspirin?

Answer 24

Gastric damage (ie. ulcers)
Dyspepsia
Nausea/Vomiting

Question 25

How do B-blockers work?

Answer 25

-ve inotropic/chronotropic effects Anti-arrhythmic effects More time in diastole - increased coronary flow

Question 26

What are the common side effects of B-blockers?

Answer 26

Bronchospasm Reduced hypoglycaemic awareness Fatigue Cardiac depression/bradycardia

Question 27

How do Nitrates work?

Answer 27

Release NO Cause venodilation - decreased preload/cardiac work Coronary vasodilatation

Question 28

What are the common side effects of Nitrates?

Answer 28

``` Headaches Flushing Burning under the tongue Postural hypotension Dizziness ```

Question 29

How do Calcium Channel Blockers work?

Answer 29

Antagonise Calcium channels - hyperpolarisation Vasodilatation Verapamil also bradycardic/myocardial depressant/anti-arrhythmic

Question 30

What are the common side effects of Calcium Channel Blockers?

Answer 30

Flushing Headaches Peripheral oedema Constipation

Question 31

How do K+ channel activators work?

Answer 31

Katp channel activated - hyperpolarisation | Vasodilatation & reduced work

Question 32

What are the common side effects of K+ channel activators?

Answer 32

``` Headaches Nausea/vomiting Flushing Dizziness Abdominal pain Ulcers ```

Question 33

What are the two common variants of stable angina?

Answer 33

Decubitus | Prinzmetal's (variant)

Question 34

What is Decubitus angina?

Answer 34

Angina precipitated by lying down Due to increased venous return Associated w/ LVF

Question 35

What is Prinzmetal's angina?

Answer 35

Occurs at rest | Due to coronary artery spasm

Question 36

What are the non-pharmacological treatment options for angina?

Answer 36

Angioplasty (PCTA) | Coronary Artery Bypass Grafting (CABG)

Question 37

Describe angioplasty (PTCA)

Answer 37

Percutaneous transluminal coronary angioplasty Dilates coronary obstructions by inflating a catheter mounted balloon Uses fluroscopy

Question 38

What are the risks of PTCA?

Answer 38

Local dissection of coronary artery Acute coronary occlusion 1% mortality, 2% AMI

Question 39

What are the long term impacts of PTCA?

Answer 39

Improves sx No prognostic benefit Requires aspirin/clopidgorel

Question 40

Describe CABG

Answer 40

Replacement of diseased artery with healthy artery from elsewhere

Question 41

What are the indications for CABG?

Answer 41

Sx control for patients unsuitable for PCI | Patients w/ 3 vessel CAD

Question 42

What are the employment/driving limitations of ACS?

Answer 42

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

Question 43

What are the employment/driving limitations of angina?

Answer 43

DVLA not notified | Driving can continue unless angina occurs at rest, whilst driving or w/ emotion

Question 44

What are the employment/driving limitations of AAA?

Answer 44

Notify DVLA if >6cm | Annual review, license revoked if >6.5cm

Question 45

How do ACS/cardiac diagnoses affect HGV drivers?

Answer 45

Revoked license for 6weeks-3mo | Re-licensing at a later date