Ischemic Heart Disease - Angina

Question 1

What 2 things so ischemic heart disease cause?

Answer 1

Angina
Myocardial infarction

Question 2

Myocardial ischemia cause what kind of symptoms?
What symptoms are these and why?

Answer 2

Anginal
Levine sign - clenched fist over chest (universal sign of isch chest pain)
Central crushing chest pain
Due to coronary artery decreased flow

Question 3

What are the 4 types of angina?

Answer 3

Stable
Unstable
Prinzmetal
Decubitis

Question 4

Stable angina
1. Symptoms?
2. Cause of pain?
3. How is it relieved?

Answer 4

Central crushing pain radiating to neck, jaw, arms

Brought in with exertion

Relieved with 5 mins rest or GTN spray

Question 5

Pathology of angina

Answer 5

Narrowing of coronary arteries
Reduced blood flow to myocardium
During increased de and, insufficient blood flow

Question 6

What is unstable angina?

Answer 6

Pain at rest, not relieved by inactivity or gtn (acute coronary syndrome)

Question 7

Stable angina —> unstable angina —> ? —> ?
The last 3 are part of what syndrome?

Answer 7

Unstable = severe ischemia

NSTEMI (non ST elevation MI)
Partial infarction

STEMI (ST elevation MI)
Transient infarction + ST elevation in local ECG leads

Acute coronary syndrome

Question 8

What is prinzmetal angina?

Answer 8

Due to coronary vasospasm (suddenly spasms & narrows) - not due to CV easel atherogenesis

Seen in cocaine users, ECG shows ST elevation

Question 9

What is decubitus angina?

Answer 9

Induced laying flat, during the night

Question 10

Risk factors of ischemic heart disease?

Answer 10

Obesity, T2DM. Hypertension, smoking, old age, male, family history, drug/ cocaine user

Question 11

What causes ischemic heart disease (angina and MI)?
Pathology

Answer 11

Atherogenesis

Fatty streak = appears in intima wall

Intermedixaute lesion = foam cells, T cells, platelets aggregate + adhere to site, inside vessel lumen

Fibours plaque (advanced) = large lesions (foam cells, T cells, smooth muscle, fibroblasts, lipid high with a nephrotic core) develop fibrous cap over top of lesion

Question 12

Endothelial damage induces cells to cite via?
And which specific ones?

Answer 12

Chemokines
IL1, IL6, IFN - Y

Question 13

When do symptoms usually start?

Answer 13

When 70 - 80% of lumen occluded

Question 14

What is stable angina in terms of in the vessel?

Answer 14

Fibrous cap is strong and less prone to rupture

If plaque prone to rupture , prothrombotic state, platelet adhesion + accumulation, progressive lumen narrowing

Question 15

Signs and symptoms of angina? How

Answer 15

Central crushing chest pain radiating to jaw/neck/left arm/shoulder
Worsens with time (doesn’t peak straight away)
NSFW - nausea, sweating, fatigue, weak breathing

(In acute coronary syndrome, hypotensive/tachycardia & impending sense of doom + palpitations )

Question 16

For angina, how do you diagnose it?

Answer 16

1st line - ECG; resting = normal, exercising = to induce ischemia = change

Gold standard: CT coronary angiography = inject contract and take CT images to view coronary arteries , shows any narrowing (70-80% occluded)

Question 17

What is the treatment for stable angina?
What 3 things do we treat for?

Answer 17

Immediate relief of symptoms
Prevent symptoms
Secondary prevention

Question 18

What do we use for immediate relief?

Answer 18

Glyceryl trinitrate (GTN)
Use with symptoms- causes vasodilation
Take GTN and rest
Doesn’t work- repeat after 5 mins
After 5 mins of still doesn’t work - call ambulance

Question 19

What do you give to Prevent symptoms?

Answer 19

1. Give a beta blocker (eg, bisoprolol) OR Ca channel blocker (eg. Amlodipine)
2. Give BB and CCB (make sure CCB is not rate limiting as can cause excessive bradycardia so give amlodipine)
3. Give both and another anti - anginal (eg, ivabrodine, nitrates), longer acting not like GTN

Question 20

What are the contraindications of BB and CCB?

Answer 20

BB = asthma

CCB = heart failure

Question 21

What do you give as secondary prevention?

Answer 21

Aspirin
Statin - atorvastatin
ACE-i - ramipril
Hypertensive treatment - Atenolol (BB)

Question 22

If pharmacological unsuccessful; specialist referral for revascularisation (doesn’t improve/get worse), what are the 2 surgeries?

Answer 22

Percutaneous coronary intervention (PCI)
Coronary Artery Bypass Graft (CABG)

Question 23

What is PCI?
Pros/cons?

Answer 23

Enter a balloon stent into coronary artery via femoral/brachial artery
+ less invasive
-risk of restenosis

Question 24

What is CABG?
Pros/cons

Answer 24

Bypass graft, take veins & sew it ont affected artery (LAD bypassed by LIMA)
+better prognosis
- more invasive

Question 25

What are some side effects of BB?

Answer 25

Tiredness, nightmares, bradycardia, erectile dysfunction, cold hands/feet