Coronary artery disease pt.1

Question 1

What can coronary artery disease be divided into?

Answer 1

Categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS)

Question 2

What are the most frequently encountered clinical scenarios in CCS?

Answer 2

The most frequently encountered clinical scenarios in patientswith suspected or established CCS are:
(i) patients with suspected CAD and ‘stable’ anginal symptoms, and/or dyspnoea
(ii) patients with new onset of heart failure (HF) or left ventricular (LV) dysfunction and suspected CAD
(iii) asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS, or patients with recent revascularization
(iv) asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization
(v) patients with angina and suspected vasospastic or microvascular disease
(vi) asymptomatic subjects in whom CAD is detected at screening
All of these scenarios are classified as a CCS but involve different risks for future cardiovascular event

Question 3

What may increase or decrease cardiac risk in patients with CCS?

Answer 3

• The risk may increase as a consequence of insufficiently controlled cardiovascular risk factors, suboptimal lifestyle modifications and/or medical therapy, or unsuccessful revascularization
• The risk may decrease as a consequence of appropriate secondary prevention and successful revascularization.

Question 4

What can the phases of CCS be divided into?

Answer 4

1- Subclinical phase
2- Recent diagnosis or revascularization
3- Long standing diagnosis

Question 5

What should a history of a patient with suspected CCS include?

Answer 5

The history should include any manifestation of cardiovascular disease (CVD) and risk factors (i.e. family history of CVD, dyslipidemia, diabetes, hypertension, smoking, and other lifestyle factors)

Question 6

Angina pectoris and sex

Answer 6

Males constitute ~70% of all patients with angina pectoris and an even greater proportion of those aged <50 years

Question 7

Typical age of a patient suspected of stable angina pectoris

Answer 7

The typical patient with angina is a man >50 years or a woman >60 years of age

Question 8

Clinical manifestation of stable angina pectoris

Answer 8

• Complains of episodes of chest discomfort, usually described as heaviness , pressure, or tightness, less often squeezing, constricting,, smothering, burning or choking and only rarely as obvious/unmistakable pain
• Shortness of breath may accompany angina, and chest discomfort may also be accompanied by less-specific symptoms such as fatigue or faintness, nausea, burning, restlessness, or a sense of impending doom
• Exacerbations of symptoms after a heavy meal or after waking up in the morning are classic features of angina
• Shortness of breath may be the sole symptom of CAD and it may be difficult to differentiate this from shortness of breath caused by other conditions
• Sharp, fleeting chest pain or a prolonged, dull ache localized to the left submammary area is rarely due to myocardial ischemia

Question 9

Localisation of discomfort by patients with CCS

Answer 9

When the patient is asked to localize the sensation, he or she typically places a hand over the sternum, sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort (Levine’s sign)

Question 10

Duration of discomfort in CCS

Answer 10

The duration of the discomfort is brief—<=10 min in the majority of cases, and more commonly just a few minutes or less (typically 2-5 mins)—and chest pain lasting for seconds is unlikely to be due to CAD

Question 11

Intensity of discomfort in CCS

Answer 11

Usually crescendo (intensifying over time)-decrescendo (decreasing in intensity over time) in nature (typically with the severity of the discomfort not at its most intense level at the outset of symptoms)

Question 12

Radiating discomfort pattern in CCS

Answer 12

• Can radiate to either shoulder and to both arms (especially the ulnar aspects of the forearm and hand)
• It also can arise in or radiate to the back, interscapular region, root of the neck, jaw, teeth, and epigastrium
• Angina is rarely localized below the umbilicus or above the mandible
• A useful finding in assessing a patient with chest discomfort is the fact that myocardial ischemic discomfort does not radiate to the trapezius muscles; that radiation pattern is more typical of pericarditis

Question 13

What are episodes of angina precipitated by?

Answer 13

• Typically are caused by exertion (e.g., exercise, hurrying, or sexual activity) or emotion (e.g., stress, anger, fright, or frustration) and are relieved by rest, they also may occur at rest (unstable angina/ACS) and while the patient is recumbent (angina decubitus)
• Angina may also be precipitated by unfamiliar circumstances, a heavy meal, exposure to cold, or a combination of these factors
• Patient may be awakened at night by typical chest discomfort and dyspnea (nocturnal angina)

Question 14

Recumbent position

Answer 14

When a person lays down horizontally:
- Supine (face and abdomen facing upwards)
- Prone (opposite of supine)
- Lateral recumbent

Question 15

What causes nocturnal angina?

Answer 15

Nocturnal angina may be due to episodic tachycardia, diminished oxygenation as the respiratory pattern changes during sleep, or expansion of the intrathoracic blood volume that occurs with recumbency
- Expansion of the intrathoracic blood volume causes an increase in cardiac size (end-diastolic volume), wall tension, and myocardial oxygen demand that can lead to
ischemia and transient LV failure

Question 16

Threshold for the development of angina pectoris

Answer 16

• May vary by time of day and emotional state
• Many patients report a fixed threshold for angina, occurring predictably at a certain level of activity, such as climbing two flights of stairs at a normal pace
• In these patients, coronary stenosis and myocardial oxygen supply are fixed, and ischemia is precipitated by an increase in myocardial oxygen demand; they are said to have stable exertional angina
• In other patients, the threshold for angina may vary considerably within any particular day and from day to day. In such patients, variations in myocardial oxygen supply, most likely due to changes in coronary vasomotor tone, may play an important role in defining the pattern of angina. A patient may report symptoms upon minor exertion in the morning yet by midday be capable of much greater effort without symptoms

Question 17

How long does it take to feel releif from exertional angina?

Answer 17

• Exertional angina typically is relieved in 1–5 min by slowing or ceasing activities and even more rapidly by rest and sublingual nitroglycerin
• Indeed, the diagnosis of angina should be suspect if it does not respond to the combination of these measures

Question 18

What can be used to describe the severity of angina?

Answer 18

Canadian Cardiac Society functional classification

Question 19

What can be used to describe the impact of angina on the functional capacity of a patient?

Answer 19

New York Heart Association functional classification

Question 20

In which patients may we see atypical presentation of myocardial ischemia? In what sense is it atypical?

Answer 20

• Women and diabetic patients
• May be atypical in location and not strictly related to provoking factors.

Question 21

What are symptoms of myocardial ischemia aside from angina called?

Answer 21

Anginal “equivalents”

Question 22

What are symptoms included in anginal equivalents?

Answer 22

They include dyspnea, nausea, fatigue, and faitness

Question 23

In who are we more likely to see anginal equivalents?

Answer 23

More common in the elderly and in diabetic patients

Question 24

What is important to cover when it comes to family history in a patient suspected of IHD?

Answer 24

It is important to uncover a family history of premature IHD (<55 years in first-degree male relatives and <65 in female relatives)

Question 25

Diagnosis of IHD

Answer 25

• Can be made with a high degree of confidence from the history and physical examination
• History of typical angina pectoris establishes the diagnosis of
  IHD until proven otherwise

Question 26

Classification of anginal symptoms

Answer 26

Typical angina Meets the following three characteristics:
(i) Constricting discomfort in the front of the chest or in the neck, jaw, shoulder, or arm;
(ii) Precipitated by physical exertion;
(iii) Relieved by rest or nitrates within 5 min.
Atypical angina: Meets two of these characteristics.
Non-anginal chest pain: Meets only one or none of these characteri

Question 27

Canadian Cardiac Society functional classification of Angina

Answer 27

Divided into 4 grades:
- Grade 1 (Angina only with strenuous exertion)
- Grade 2 (Angina with moderate exertion)
- Grade 3 (Angina with mild exertion)
- Grade 4 (Angina at at rest)

Question 28

What would put a patient as grade 1 angina in the Canadian Cardiac Society functional classification of Angina?

Answer 28

• Ordinary physical activity, such as walking and climbing stairs, does not cause angina
• Angina present with strenuous or rapid or prolonged exertion at work or recreation

Question 29

What would put a patient as grade 2 angina in the Canadian Cardiac Society functional classification of Angina?

Answer 29

• Slight limitation of ordinary activity
• Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or when under emotional stress or only during the few hours after awakening
• Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions

Question 30

What would put a patient as grade 3 angina in the Canadian Cardiac Society functional classification of Angina?

Answer 30

Marked limitation/difficulty of ordinary physical activity
- Walking one to two blocks on the level and climbing one flight of stairs at normal pace

Question 30

What would put a patient as grade 4 angina in the Canadian Cardiac Society functional classification of Angina?

Answer 30

No exertion needed to trigger angina

Question 31

New York Heart Association functional classification of Angina

Answer 31

Similar to Canadian version in description (4 grades and with each grade having same description as Canadian version)