CVS Angina Pectoris

Question 1

Pathophysiology

Answer 1

Atherosclerosis - MI Mostly atheroma Anaemia AS Tachyarrythmias Arteritis

Question 2

Risk Factors - modifiable

Answer 2

HTN DM SMoking Increased cholesterol Obesity

Question 3

Risk Factors non modifiable

Answer 3

Age Mal FH (MI <55 yrs) Genetic e.g. hyperlipidaemia

Question 4

Symptoms

Answer 4

Central chest tightness or haeviness Brought on by exertion, relieved by rest May radiate to one/both arms, neck, jaw or teeth

Question 5

Precipitating factors

Answer 5

Emotion Cold weather Heavy meals

Question 6

Classification

Answer 6

Stable Unstable Decubitus Prinzmetal’s/variant Syndrome X

Question 7

Stable

Answer 7

induced by effort

Question 8

Unstable

Answer 8

Occurs at rest/ minimal exertion

Question 9

Decubitus

Answer 9

induced by lying down

Question 10

Prinzmetals/variant

Answer 10

Occurs during rest 1. Due to coronary spasm 2. ST elevation during attack: resolves as pain subsides

Question 11

Treatment of prinzmetals

Answer 11

CCB and long-acting nitrate

Question 12

Syndrome X

Answer 12

Angina + pain + ST elevation on exercise test but no evidence of coronary atherosclerosis

Question 13

Differentials for angina

Answer 13

AS Aortic aneurysm GI: GORD, spasm Musculoskeletal

Question 14

Investigations

Answer 14

Bloods: FBC, U and E, lipids, glucose, ESR, TFTs ECG: usually normal (may show ST depression, flat/inverted T waves, past MI Consider excercise ECG Stress echo Perfusion scan CT coronary Calcium store Angiography (gold standard)

Question 15

Management

Answer 15

Lifestyle Medical Interventional Surgical

Question 16

Lifestyle

Answer 16

Stop smoking Weight loss and increase exercise Healthy diet: oily fish, fruit, veg, reduced

Question 17

Medical secondary prevention

Answer 17

Prevent cardiovascular events. 1. Aspirin 75mg OD 2. ACEi (esp. angina + DM) 3. Statins: simvastatin 40mg 4. Antihypertensives

Question 18

Anti-anginals - preventing episodes

Answer 18

GTN (spray or SL) + either 1st: Beta blockers e.g. Atenolol 50-100mg OD 2nd: CCB (Verapamil 80mg TDS

Question 19

Interventional: PCI indecations

Answer 19

Poor response to medical treatment Refractory angina but not suitable for CABG

Question 20

Interventional PCI complications

Answer 20

Re-stenosis (20-30% @ 6mo) Emergency CABG (<0.5%)

Question 21

Reducing the risk of re-stenosis

Answer 21

Clopidogrel Bare metal stent: 1mo Drug-eluting (e.g. sirolimus) stent: 1 yr

Question 22

Surigcal: CABG indications

Answer 22

L main stem disease Triple vessel disease REfractory angina Unsuccessful angioplasty

Question 23

Complications of CABG

Answer 23

MI Stroke Pericardial tamponade o haemothorax Postperfusion syn. Post-op AF Nonunion of sternum Graft stenosis