Ischemic Heart Disease - Angina Flashcards
What 2 things so ischemic heart disease cause?
Angina
Myocardial infarction
Myocardial ischemia cause what kind of symptoms?
What symptoms are these and why?
Anginal
Levine sign - clenched fist over chest (universal sign of isch chest pain)
Central crushing chest pain
Due to coronary artery decreased flow
What are the 4 types of angina?
Stable
Unstable
Prinzmetal
Decubitis
Stable angina
1. Symptoms?
2. Cause of pain?
3. How is it relieved?
Central crushing pain radiating to neck, jaw, arms
Brought in with exertion
Relieved with 5 mins rest or GTN spray
Pathology of angina
Narrowing of coronary arteries
Reduced blood flow to myocardium
During increased de and, insufficient blood flow
What is unstable angina?
Pain at rest, not relieved by inactivity or gtn (acute coronary syndrome)
Stable angina —> unstable angina —> ? —> ?
The last 3 are part of what syndrome?
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
What is prinzmetal angina?
Due to coronary vasospasm (suddenly spasms & narrows) - not due to CV easel atherogenesis
Seen in cocaine users, ECG shows ST elevation
What is decubitus angina?
Induced laying flat, during the night
Risk factors of ischemic heart disease?
Obesity, T2DM. Hypertension, smoking, old age, male, family history, drug/ cocaine user
What causes ischemic heart disease (angina and MI)?
Pathology
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
Endothelial damage induces cells to cite via?
And which specific ones?
Chemokines
IL1, IL6, IFN - Y
When do symptoms usually start?
When 70 - 80% of lumen occluded
What is stable angina in terms of in the vessel?
Fibrous cap is strong and less prone to rupture
If plaque prone to rupture , prothrombotic state, platelet adhesion + accumulation, progressive lumen narrowing
Signs and symptoms of angina? How
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 )
For angina, how do you diagnose it?
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)
What is the treatment for stable angina?
What 3 things do we treat for?
Immediate relief of symptoms
Prevent symptoms
Secondary prevention
What do we use for immediate relief?
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
What do you give to Prevent symptoms?
- Give a beta blocker (eg, bisoprolol) OR Ca channel blocker (eg. Amlodipine)
- Give BB and CCB (make sure CCB is not rate limiting as can cause excessive bradycardia so give amlodipine)
- Give both and another anti - anginal (eg, ivabrodine, nitrates), longer acting not like GTN
What are the contraindications of BB and CCB?
BB = asthma
CCB = heart failure
What do you give as secondary prevention?
Aspirin
Statin - atorvastatin
ACE-i - ramipril
Hypertensive treatment - Atenolol (BB)
If pharmacological unsuccessful; specialist referral for revascularisation (doesn’t improve/get worse), what are the 2 surgeries?
Percutaneous coronary intervention (PCI)
Coronary Artery Bypass Graft (CABG)
What is PCI?
Pros/cons?
Enter a balloon stent into coronary artery via femoral/brachial artery
+ less invasive
-risk of restenosis
What is CABG?
Pros/cons
Bypass graft, take veins & sew it ont affected artery (LAD bypassed by LIMA)
+better prognosis
- more invasive
What are some side effects of BB?
Tiredness, nightmares, bradycardia, erectile dysfunction, cold hands/feet
