IHD Flashcards
Aetiology
Angina is chest pain caused by and insufficient blood supply - caused by CAD narrowing in the lumen. Less commonly can be caused by valve disease.
Complications
Risk Factors
Stroke, MI, death
Age, gender, FH, ethinicity, smoking, cholesterol (low HDL and high LDL), lack of exercise, alcohol, HTN, DM, AF, RA, CKD
Symptoms
Typical angina?
Atypical angina?
Pain in the chest (neck, shoulders, jaws or arms)
Stable angina - with physical exertion or emotional stress
Unstable angina - pain at rest, immediate admission
Tpical angina presents with:
- Precipitated by physical exertion.
- Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
- Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
Atypical angina presents with two of the above features. Other symptoms include gastrointestinal discomfort, and/or breathlessness and/or nausea.
Investigations
Specialist chest pain service to confirm
12- lead ECG
- ischaemia or previous MI indicated by pathological Q waves, LBBB, ST segment abnormalities
Do not use exercise to diagnose
Investigations
Specialist chest pain service to confirm
12- lead ECG
- ischaemia or previous MI indicated by pathological Q waves, LBBB, ST segment abnormalities
Do not use exercise to diagnose
Advice
Instruct the person that if they experience chest pain they should:
- Stop what they are doing and rest.
- Use their glyceryl trinitrate spray or tablets as instructed.
- Take a second dose after 5 minutes if the pain has not eased.
- Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.
until the diagnosis is confirmed only if chest pain is considered likely to be stable angina.
Explain risk factors, explore misconceptions
Medication
GTN spray
Beta blocker or CCB
Do not combine a beta-blocker with a rate-limiting CCB (diltiazem or verapamil), as severe bradycardia and heart failure can occur.
For secondary prevention:
- Consider prescribing aspirin (75 mg daily)
- ACEi
- statins
Monitoring/ Follow up
Review response to treatment within a month
Review the patients every 6 months to 1 year - assess CVD risk, complications
Hospital admission
Consider hospital admission for people with the following symptoms, as they may have unstable angina:
- Pain at rest (which may occur at night).
- Pain on minimal exertion.
- Angina that seems to be progressing rapidly despite increasing medical treatment.
Indications for early referral to a cardiologist include:
- Previous MI, CABG or percutaneous transluminal coronary angioplasty and development of angina.
- ECG (electrocardiographic) evidence of previous myocardial infarction or other significant abnormality.
- Newly diagnosed atrial fibrillation and angina.
- Heart failure and angina.
- An ejection systolic murmur suggesting aortic stenosis.
- Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG).
GTN
How it works?
Side effects?
Sprayed under the tongue. Nitrates cause vasodilation of the coronary vessels.
Postural hypotension after administration, headache, burning, stinging or tingling of the mouth
Can take up to three sprays of 1/2 doses. Wait 5 minutes between doses, and only take 3
When to suspect ACS?
ACS - unstable angina and MI
Suspect acute coronary syndrome, if:
Pain in the chest or other areas (for example the arms, back, or jaw) lasts longer than 15 minutes.
Chest pain is:
Associated with nausea and vomiting, sweating or breathlessness, or a combination of these.
Associated with haemodynamic instability (for example the person has a systolic blood pressure less than 90 mmHg).
Of a new-onset, or is the result of an abrupt deterioration of stable angina; with pain occurring frequently with little or no exertion, and often lasting longer than 15 minutes.
ECG, Troponin
Treatment of ACS
- coronary angioplasty (PCI)
- thrombolysis
- CABG - usually if LAD is blocked
