Diseases Flashcards
What are the three features present in typical anginal pain?
Substernal chest discomfort
Provoked by stress or exercise
Relieved with rest or glyceryl trinitrate
Define atypical anginal pain.
2 of the following:
Substernal chest discomfort
Provoked by stress or exercise
Relieved with rest or glyceryl trinitrate
How can unstable angina present?
Rest Angina: usually lasting more than 20 mins, within 1 week of presentation
New onset angina (within 2 months of initial presentation) and Class III severity
Increasing Angina: previously diagnosed angina that is more frequent, longer in duration or occurs at a lower threshold.
Angina occurring after a recent episode of MI
What are the signs in angina?
Typically normal in chronic stable angina
What are the risk factors for angina?
Age (>45yrs for men >55yrs for women) Positive family history for CAD Male Smoking Ilicit drug use Hyperlipidaemia Isolated low HDL Obesity Inactivity Hypertension Diabetes Stroke or peripheral arterial disease
What are the exacerbating factors for angina?
Thyroid Disease Anaemia Hyperviscosity Syndrome AV fistula Underlying lung disease
What is chest discomfort?
Chest pain that only meets one criteria for angina
What first line investigations would you of in angina?
Resting ECG: often normal, ST changes suggestive of ischaemia, Q waves may indicate prior infarction
Haemoglobin: anaemia, increased cardiac workload (<90 g/L)
Fasting lipid Profile: hyperlipidaemia part of metabolic syndrome (increased LDL, low HDL is protective)
Fasting blood glucose of HbA1c; elevated in diabetes (hyperglycaemia part of metabolic syndrome)
What are investigations to consider in angina?
TSH: (elevated) hyperthyroidism increases metabolic demand and cardiac workload
(decreased) Hypothyroidism is associated with dyslipidaemia and ischaemic heart disease
Stress exercise ECG without imaging: St segment elevation or depression to identify ischaemia
Stress SPECT/ stress echocardiography/ stress cardiac magnetic resonance/ stress PET: Identify wall motion or perfusion abnormalities
CCTA (cardiac CT angiography): narrowing of the lumen
What are the differentials of angina?
Aortic Dissection (intrascapular sharp tearing pain)
Unstable Angina/ Acute Coronary Syndrome (increasing frequency duration or severity)
GORD (burning sensation after food)
Pulmonary Embolism (dyspnoea, DVT)
Pneumothorax (chest pain, dyspnoea, cough)
What is the management of angina?
Ist line: lifestyle education, weight management, exercise, smoking cessation, lipid goals, discussion on better management of diabetes
PLUS sublingual glyceryl trinitrate
PLUS antiplatelet therapy (primary option is aspirin, secondary is clopidogrel)
Adjunct: Anti-anginal therapy: bisoprolol, nifedipine, glyceryl trinitrate transdermal
ADJUNCT: Atrovastatin (any statin), rampril
Blood sugar control, revascularisation
How do you differentiate between STEMI, NSTEMI and unstable angina?
STEMI has ST segment elevation or a new left bundle branch block
NSTEMI and unstable angina have ST depression and/or T wave inversion
NSTEMI: elevated cardiac biomarkers
Unstable Angina: cardiac biomarkers aren’t raised
What is the presentation of unstable angina?
Increasing frequency (daily or several times a day) and severity of pain (occur at rest, decreased levels of activity)
Retrosternal pressure radiating to the jaw, arm, neck that is improved by nitrates
Dyspnoea (may occur by itself)
Fourth heart sound indicates reduced myocardial relaxation due to ischaemia
May present with pain in epigastric region, pleuritic chest pain
Diaphoresis
Nausea
Tachycardia (may get AF)
Carotid Bruit
What first line investigations would you do in unstable angina?
ECG: normal/ transient ST segment depression/ T wave inversion
Cardiac Biomarkers: not elevated
FBC: Hb may be normal or low
Electrolytes and Renal Function (baseline test and risk stratification, renal function is an independant predictor for mortality): normal
Blood Sugar (risk stratification): normal/ elevated in diabetes
Lipid Profile (for risk stratification): normal or increased total cholesterol and LDL
Coagulation profile (as a baseline as treatment option affect coagulation: normal
CXR: usually normal
Echo at rest (used if ECG is inconclusive): transient regional wall motion abnormalities
Myocardial Perfusion Study: rest (used if ECG is inconclusive) resting perfusion defect
CT chest or MRI: Indicated for exclusion of pulmonary embolism or aortic dissection
Coronary Angiography: gold standard shows stenosis of coronary artery and allows for treatment such as angioplasty and stenting
Why would you do a chest X-ray in someone with angina?
Excludes other diagnosis
Heart failure: pulmonary oedema
Aortic Dissection: wide mediastinum
Pulmonary Embolism: hyper-lucent lung field
Pulmonary Infarction: Wedge-shaped infarct
Pneumonia: Consolidation
Pneumothorax:
collapsed lung
Perforated Viscus: Air under the diaphragm
