Coronary heart disease Flashcards
What is angina?
Angina is caused by coronary artery disease
=> atherosclerotic plaque in the coronary artery cause progressive narrowing of lumen
=> symptoms occur with reduced blood flow and increased oxygen demands
=> less commonly, angina is caused by valvular disease e.g. aortic stenosis
a) Stable angina = occurs with physical exertion or emotional stress. Lasts no more than 10 mins and relieved with rest ± GTN spray
b) Unstable angina = new onset angina or deterioration in previous stable angina. Symptoms occurring at rest
What are the risk factors of angina?
Non-modifiable and modifiable
Co-morbidity that increase risk of CVD
Non-modifiable:
- Age (mainly >50 years)
- Gender (men>women)
- Family hx of CVD
- Ethnic background e.g. south asian and african at an increased risk
Modifiable:
- Smoking
- Low blood levels of HDL cholesterol
- High levels of non HDL cholesterol
- Sedentary lifestyle / lack of physical activity
- Unhealthy diet
- Alcohol above recommended limits
- Overweight / obesity
Comorbidities:
- Hypertension
- Diabetes
- CKD
- Dyslipidaemia (drugs i.e. antipsychotics, immunosuppressants and steroids can cause dyslipidaemia)
- AF
- Anxiety
What are the complications of angina caused by coronary artery disease?
- MI
- Unstable angina
- Sudden cardiac death
- Stroke
- Anxiety & depression
- Reduced quality of life
Assessment of stable chest pain:
How do you classify typical and atypical angina?
What factors make angina more likely than others?
- Typical angina presents with all 3 features:
=> pain precipitated by physical exertion
=> constricting chest pain, in the neck, shoulders, jaws or arms
=> relieved by rest or GTN within about 5 mins - Atypical angina presents with two of the above features and
=> GI discomfort ± breathlessness ± nausea - Factors that make a diagnosis of angina likely:
=> Increasing age
=> Male sex
=> Presence of CVD
=> Hx of established coronary artery disease i.e. previous MI
Factors that make a diagnosis of angina unlikely:
=> Continuous or prolonged pain
=> Pain unrelated to activity
=> Pain on breathing
=> Pain assoc. with dizziness, palpitations, tingling and difficulty swallowing
How is stable angina investigated and diagnosed?
Clinical diagnosis
- ECG to exclude coronary syndrome, pathological Q waves, LVH, left bundle branch block
- Lab tests:
=> fasting blood glucose & HbA1c, fasting lipid profiles, U&E for CVD risk profile
=> FBC to check for anaemia - can exacerbate stable angina
=> Thyroid function test - CXR - for atypical presentation, pulmonary disease, HF
If stable angina can’t be excluded by clinical assessment alone e.g. symptoms consistent with typical or atypical angina or ECG changes
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
3rd line: invasive coronary angiography
*can organise a 12-lead ECG if angina cannot be excluded clinically - an abnormal ECG makes CHD more likely but doesn’t confirm stable angina
Whilst awaiting diagnostic testing results, how do you manage a person with suspected stable angina?
GTN spray for symptoms relief whilst waiting specialist referral
Instruct patient that if they experience chest pain:
=> stop what they are doing and rest
=> use their GTN spray
=> take a second dose after 5 mins if pain has not eased
=> call 999 if the pain has not eased 5 mins after second dose or earlier if the pain is intensifying / person unwell
How do you manage a person with new diagnosis of angina?
Explain the diagnosis of stable angina to the person.
=> The explanation should include: factors which provoke angina i.e. exertion, emotional stress, exposure to cold, or eating a large meal.
The long-term progression and prognosis of angina.
Information on how angina is managed.
Encourage the person to ask questions about their angina and its management.
Explore and address any misconceptions the person might have about their angina. This includes:
Implications for daily activities.
Risk of myocardial infarction.
Life expectancy.
Advise the person to seek medical help if there is a sudden worsening in the frequency or severity of their angina.
Discuss the reasons for treatment, as well as the benefits and adverse effects (such as flushing, headache, and light-headedness).
Provide information on how to use a short-acting sublingual nitrate and when to administer it.
Assess the person’s need for lifestyle advice to manage their cardiovascular risk.
Explore and address issues according to the person’s needs, which may include:
=> Self-management skills such as pacing their activities and goal setting.
=> Concerns about the impact of stress, anxiety, or depression on angina.
=> Advice about physical exertion including sexual activity.
=> Advice about other activities such as driving, flying, and work.
=> Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent CVD i.e heart attack and stroke
What drug treatment is prescribed for a person with stable angina?
- GTN spray for symptomatic relief and to use before performing activities known to cause symptoms of angina
- Prescribe a beta-blocker or a CCB as first line regular treatment to reduce symptoms of stable angina
=> If not controlled on CCB alone at optimum dose then add beta-blocker and vice-versa
=> Rate limiting CCB i.e. verapamil or diltiazem if used as monotherapy; if used in combination with beta blocker then use nifedipine.
*beta-blocker should not be prescribed concurrently with verapamil = risk of complete heart block
=> if neither tolerated, use long acting nitrate i.e. isosorbide mononitrate, nicorandil, ivabradine, ranolazine
=> Review response to treatment in 2-4 weeks
- Anti-platelet treatment (low dose aspirin 75mg) and statin in all patients with stable angina
How to manage CVD risk in person with angina?
a) Advice on work
b) Advice on driving
c) Advice on sex
- Optimize management of comorbidities
- Stop smoking
- Cardioprotective diet (fish, fruit & veg, fibre, less sugar, saturated fats, salt)
- Healthy weight - exercise at least 30 mins per day
- Limit alcohol consumption (14 units/week spread over 3 days or more)
Work: continue as before. If involves heavy manual work, may need to alter practice to adapt => discuss issue with occupational health department at work
Driving: Group 1 (cars) - cease driving if symptoms at rest, with emotions or whilst driving. Can resume when symptom controlled. Do not need to notify DVLA.
Group 2 (lorries/buses) - must not drive and notify DVLA when symptoms occur. Driving license may be revoked if symptoms continue. Re-licenced if free from angina for at least 6 weeks / no other disqualifying condition.
Sex: can continue as normal. If sex brings on angina, then take GTN immediately before sex to prevent attacks.
Sildenafil is contraindicated with GTN.
What is the next step in management if the patient still has symptomatic angina on two anti-anginas drugs?
Consider for revascularisation
PCI: single vessel disease ; multi-vessel <65 years ; suitable anatomy
CABG: Unsuitable anatomy ; multi-vessel disease >65 years ; diabetes
What is QRISK2?
Explain to patient.
QRISK2 is a tool to calculate the likelihood of you having a stroke or heart attack in the next 10 years.
The higher the score, the greater the risk and the more risk factors you have, the greater the risk.
Risk factors include: => Age, gender, ethnicity => High BP, cholesterol levels, BMI => Smoking and alcohol => Medical condition i.e. diabetes, CKD => Strong family hx of heart disease in relatives under 60 years
The risk of CVD naturally increases with age but all these other factors further increase it.
QRISK2 score tells you weather you are at a low, moderate or high risk of developing CVD in the next 10 years.
- Low risk = QRISK2 score of less than 10%
=> this means you have less than 1 in 10 chance of having a stroke or heart attack in the next 10 years - Moderate risk - QRISK2 of 10-20%
=> This means that you have 1-2 in 10 chance of having a stroke or heart attack in the next 10 years - High risk - QRISK2 score of >20%
=> This means you have at least a 2 in 10 chance of having a stroke or heart attack in the next 10 years.
How can you lower your QRISK?
NICE suggests QRISK of >10% = offered help to reduce their risk by making lifestyle changes.
=> Stop smoking – consider swapping to vaping initially which is considerably less risky.
=> Eat a healthy balanced diet - low in fat, sugar and salt. Eat 5 fruit / veg a day.
=> Reduce alcohol intake – aim for less than 14 units a week for men and women spread over 3 days
=> Keep an eye on your weight and take steps to lose weight if needed. Aim for BMI 20-25.
=> Exercise regularly 30 mins / day (walking is a great start).
=> Taking medication to reduce blood pressure if needed.
*can measure QRISK again in 6-12 months time to measure weight, height, BP and cholesterol levels to monitor progress.
If lifestyle changes ineffective, add statin (20mg atorvastatin), to be taken every night
QRISK Above 20% = STATIN
=> Statins can significantly reduce risk of heart attack and stroke by unto 25%.
Acute coronary syndrome comprises unstable angina, STEMI and NSTEMI.
What is the underlying pathophysiology of ACS?
Rupture of the fibrous cap of a coronary artery plaque.
This leads to platelet aggregation and adhesion, localised thrombosis, vasoconstriction & distal thrombus embolisation.
Presence of a rich lipid core and think fibrous cap = increased risk of rupture.
Thrombus formation and vasoconstriction produced by platelet release of serotonin and thromboxane-A2 => myocardial ischaemia due to reduction in coronary blood flow.
How do you differentiate between unstable angina and NSTEMI?
NSTEMI: occluding thrombus => myocardial necrosis and a rise in serum troponin I & T and creatinine kinase-MB.
Unstable angina: ruptured plaque with non-occlusive thrombus + no rise in troponin
No ST elevation in both
What are the risk factors in ACS?
Non-modifiable:
Age
Male
Family Hx of ischaemic heart disease (MI in 1st degree relative <55years)
Modifiable: Smoking Hypertension Diabetes Hyperlipidaemia Obesity Sedentary lifestyle Cocaine use
Controversial risk factor:
Stress
Type A personality
Left ventricular hypertrophy
