Ischaemic heart disease: angina

Question 1

Define angina

Answer 1

Angina = a type of IHD

Question 2

Describe the epidemiology of angina (and IHD)

Answer 2

• In UK: 1 in 7 men and 1 in 11 women die from IHD
• Responsible for almost 70,000 deaths in UK per year
• Avg of 190 people each day

Question 3

Describe the aetiology (causes) of angina

Answer 3

1. ) >70% stenosis of coronary arteries

2. ) Coronary artery spasms

Question 4

Describe the pathophysiology of angina

Answer 4

• Stable angina: when coronary artery has a build up of atherosclerotic plaque. This will narrow the artery, resulting in reduced blood flow to the sub endocardium. This sub endocardium experiences ischaemia (but is not necrosis yet: that’s an MI). The body releases adenosine and bradykinin in response which causes pain that can radiate to the jaw/neck/arms
• The pain is a squeezing pain in the chest
• Unstable angina: when the atherosclerotic plaque

Question 5

Describe the pathophysiology of angina

Answer 5

• Stable angina: when coronary artery has a build up of atherosclerotic plaque. This will narrow the artery, resulting in reduced blood flow to the sub endocardium. This sub endocardium experiences ischaemia (but is not necrosis yet: that’s an MI). The body releases adenosine and bradykinin in response which causes pain that can radiate to the jaw/neck/arms
• The pain is a squeezing pain in the chest
• Unstable angina: when the atherosclerotic plaque ruptures and thrombosis takes place. Feel chest tightness from exertion AND rest
• P Angina: get transmural ischaemia and can lead to MI

Question 6

What are the clinical presentations of angina: signs

Answer 6

1. ) ST depression if stable/unstable due to lack of blood supply to sub endocardium and ST elevation if P angina
2. )Chest pain coming on with exertion and rapidly resolved by rest/GTN
3. ) Pain exacerbated by cold weather/anger/excitement

Question 7

What are the clinical presentations of angina: symptoms

Answer 7

1. ) Central crushing retrosternal chest pain that radiates to arms/jaw/neck
2. ) Shortness of breath upon exertion
3. ) Dyspnoea (excessive sweating)
4. ) Palpitations
5. ) Syncope

Question 8

Describe the investigations for angina (gold standard/first line etc)

Answer 8

1. ) Gold standard: CT coronary angiography: where a medium is injected and when the heart beats, pictures are taken to see where the narrowing/stenosis is
2. ) 12 lead ECG: ST depression and T wave inversion (could be normal too)
3. ) FBC: see if patient has anaemia (also check for glucose and cardiac enzymes)
4. ) Lipid profile:
5. ) CXR: check heart size and pulmonary vessels

Question 9

What is the differential diagnosis for angina

Answer 9

• Pericarditis/myocarditis
• Pulmonary Embolism
• Chest infection
• GORD
• Dissection of aorta

Question 10

Describe the management of angina

Answer 10

1. ) GTN (glycerol trinitrate) spray: if they take this and rest but still don’t feel better call 999. GTN spray acts as a vasodilator and will result in coronary artery dilating to improve blood flow
2. ) Medications: to prevent symptoms
   - beta blocker: bisoprolol
   - calcium channel blocker
3. ) Medications to prevent secondary cardiovascular symptoms: The four A’s
   - A: aspirin - 80mg OD
   - A: atorvastatin - 80 mg OD
   - A: ACE inhibitor e.g. Ramipril
   - A: atenolol beta blocker)
4. ) Surgical interventions:
   - PCI (percutaneous coronary intervention) : where medium is inserted into the brachial/femoral vein. Via X-ray the stenosis is visible and a catheter can be used to expand the area of stenosis
   - CABG (coronary artery bypass graft): where a vein is taken from the leg e.g. part of the great saphenous vein and a midline sternotomy will open the chest and sew the vein to bypass the part of the stenosis: has a longer recovery rate w/more complications but very effective
5. ) Education + lifestyle modifications:
   - Physical activity/cardiac rehabilitation
   - Diet therapy
   - Weight management
   - Smoking cessation