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Year 3: Cardiovascular > Ischemic Heart Disease: Unstable angina (Complete) > Flashcards

Ischemic Heart Disease: Unstable angina (Complete) Flashcards

1
Q

Define unstable angina

A

Myocardial ischaemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis.

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2
Q

What are typical ECG findings in patients with unstable angina in comparison to MI? (5)

A

No evidence of ST-elevation MI

ECG may be normal

ECG may show transient ST-elevation

ECG may show ST-deppresion

ECG may show T-wave inversion

N.B. The ECG must not show changes from previous ECG readings. If it does, points towards other causes

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3
Q

How does unstable angina compare to MI in terms of troponin findings?

A

Unstable angina shows no cardiac troponin elevation (indicating no cardiomyocyte injury or necrosis).

MI would show elevated levels

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4
Q

What is the most common underlying cause of acute myocardial ischaemia (e.g. unstable angina)?

A

Coronary artery disease

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5
Q

A less common/rare cause of acute myocardial ischaemia characterised by intense vasospasms of the coronary arteries is known as?

A

Varient angina or Prinzmetal’s angina

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6
Q

MI can also display a normal or non ST-elevated ECG. This subtype of MI is known as?

A

NSTEMI (Non-ST elevation myocardial infarction)

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7
Q

How can a NSTEMI and unstable angina be differentiated?

A

NSTEMI would show elevated troponin levels whereas unstable angina would show no elevation.

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8
Q

An acute coronary syndrome (e.g. unstable angina, MI) should always be suspected in patients presenting with which key features? (4)

A

Must have presented with acute chest pain which includes pain in other areas (e.g. neck, jaw, arm) and any of these features:

Pain has lasted more than 15 minutes

Associated symptoms including: Nausea, vomitting, sweating, breathlessness

New in onset or occurs in patient with known history of stable angina

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9
Q

How is unstable angina chest pain typically described as being?

A

Pressure

Tightness

Burning

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10
Q

What are some atypical presentations of unstable angina that should be considered? (5)

A

Epigastric pain

Indigestion

Isolated dyspnoea

Isolated syncope

Back pain (Middle/Upper) [Typical in woman]

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11
Q

Atypical presentations of unstable angina chest pain is most common in which groups of patients? (4)

A

Woman

Diabetes

Chronic kidney disease

Dementia

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12
Q

What 8 investigations should always be ordered in patients suspected of having an acute coronary syndrome?

A

Bedside: 12-lead ECG

Bloods: FBC, U&Es, LFTs, Troponin, Glucose, CRP

Imaging: CXR

High sensitivity troponin (within 60 minutes)

CXR (rules out other causes e.g. pneumothorax, aortic dissection or complications of acute coronary syndrome such as pulmonary oedema)

Full blood count (assessed to estimate risk of bleeding [thrombocytopenia] or suspect bleeding as a secondary cause)

Urea, electrolytes, and creatinine (determine choice of anticoagulant)

Liver function tests (to assess bleeding risk before anticoagulation therapy)

Blood glucose (identify hypo or hyperglycaemia)

C-reactive protein (to rule out other infective causes of acute chest pain, e.g. acute pneumonia)

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13
Q

What essential questions must be asked when taking the history of patients presenting with acute chest pain? (4)

A

Is the patient experiencing the chest pain now and if not when was the last episode? (helps to determine timing of high troponin sensitivity).

History and character of chest pain including: Have they experienced this type of pain before?
SOCRATES.

Check for risk factors

Previous investigations for chest pain

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14
Q

List some risk factors for unstable angina (12)

A

Diabetes

Hyperlipidaemia

Hypertension

Metabolic syndrome

Renal impairment

Peripheral arterial disease

A history of ischaemic heart disease and any previous treatment

Obesity

Advanced age

Smoking

Cocaine use

Physical inactivity

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15
Q

List some risk factors for unstable angina (12)

A

Diabetes

Hyperlipidaemia

Hypertension

Metabolic syndrome

Renal impairment

Peripheral arterial disease

A history of ischaemic heart disease and any previous treatment

Obesity

Advanced age

Smoking

Cocaine use

Physical inactivity

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16
Q

What 3 medications should be checked for before administering treatment to patients suspected of unstable angina?

A

Anticoagulants

Antiplatelet drugs

Recent use of phosphodiesterase inhibitors (sildenafil, vardenafil, or tadalafil) [Used in COPD, BPH, erectile dysfunction)

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17
Q

What allergies should be checked for in patients suspected of having unstable angina before treating them?

A

Check for hypersensitivity to aspirin

18
Q

What are typicial presentations that can be found on physical examination of patients suspected of unstable angina?

A

Physical examinations may be normal however some patients may have significant sweating

19
Q

What findings on physical examination are very atypical in patients with unstable angina and should instead drive suspicion more towards an acute MI? (3)

A

Low blood pressure

Evidence of left ventricular failure

Life threatnening arrythmias (e.g. ventricular tacchycardia or fibrilation)

20
Q

What is a typical presentation of chest pain caused by unstable angina?

A

Pain is retrosternal

Described as pressure, tightness or burning

Radiating to the left arm, both arms, right arm, neck, or jaw.

Pain can be consistent or intermittent

21
Q

List examples of differentials to consider in patients with unstable angina (8)

A

Stable angina

Myocardial infarction (STEMI and non-STEMI)

Congestive heart failure

Aortic dissection

Pericarditis

Myocarditis

Pulmonary embolism

Chest wall pain

Pneumothorax

Perforated abdominal viscus

22
Q

How does the presentation of stable angina differ to unstable angina? (3)

A

Pain occurs only in context of exertion or emotional stress

Pain is not worsened over time

Pain is relieved by nitrates or rest

23
Q

How does the presentation of MI differ to unstable angina?

A

Clinical presentations may be indistinguishable so must be ruled out via investigations (e.g. CXR, troponin)

24
Q

How does the presentation of congestive heart failure differ to unstable angina? (2)

A

Presents more predominantly with SoB, Dysponoea, Orthopnea.

Chest pain my occur if coronary perfusion is poor

25
Q

How does the presentation of chest wall pain differ to unstable angina? (3)

A

Pain replicated on movement or palpation.

Pain not relieved by rest or nitrates but may be relieved by local injection of lidocaine

26
Q

How does the presentation of pericarditis differ to unstable angina? (4)

A

Pain relieved when sitting up and leaning forward.

Pain worsened when supine

Pericardial rub may be heard

Have history of recent myocardial infarction, renal failure, chest irradiation, or associated connective tissue disease.

27
Q

How does the presentation of myocarditis differ to unstable angina?

A

May have had a recent viral infection

Chest pain is sometimes pleuritic

More likely to present with signs of heart failure (e.g. peripheral oedema, dyspnoea), palpitations or fatigue

28
Q

How does the presentation of aortic dissection differ to unstable angina? (3)

A

Chest pain is often tearing and radiates to the back between the shoulder blades

May have a medical history of hypertension, Marfan’s or Ehler’s Danlos syndrome.

May have radio-radial delay, diastolic murmur or aortic regurgitation

29
Q

How does the presentation of a pulmonary embolism differ to unstable angina? (3)

A

Present with acute presentations of SoB, pleuritic chest pain or syncope.

May present with hypoxia, cyanosis, elevated jugular venous pressure with hypotension, and clear lung fields.

May have a history of: Recent surgery, immbolisation, air travel, cancer

30
Q

How does the presentation of a pneumothorax differ to unstable angina? (3)

A

Acute chest pain with shortness of breath

May have tracheal deviation, hyperesonance of decreased breath sounds.

Underlying lung disease, trauma, or recent procedures (such as insertion of central venous line).

31
Q

How does the presentation of a perforated abdominal viscus (aka bowel peforation) differ to unstable angina? (3)

A

Typically presents with abdominal pain. Chest pain is referred but may be mistaken for cardiac origin.

Abdominal examination shows localised tenderness and, in cases of peritonitis, generalised tenderness.

History of previous peptic ulcer disease, diverticulitis, or recent bowel biopsy.

N.B. CXR also shows gas bubble under diaphragm

32
Q

What is the initial management plan for patients presenting with unstable angina? (5)

A

300mg Aspirin (Check for allergies or significant bleeding risk) and Fondaprinux (antithrombin)

Give pain relief (3 doses of translingual/sublingual glyceryl trinitrate)

Calculate GRACE (mortality predictor)

For low risk mortality: Give aspirin and ticagrelor OR aspririn and clopidogrel (P2Y12 inhibitor) if bleeding risk.

For intermediate/high risk mortality: Angioplasty if unstable, ticagrelor and aspirin.

Replace tricagrelor with prasugrel if undergoing a PCI (angioplasty with stenting)

33
Q

Name the antithrombin administered to patients with unstable angina

A

Fondaprinux

34
Q

Name the painkiller administered to patients with unstable angina

A

glyceryl trinitrate

35
Q

List 2 examples of types of P2Y12 inhibitors

A

Clopidogrel

Prasugrel

36
Q

What is the long term management plan for patients with unstable angina?

A

Start or increase dosage of anti-anginal medication:

Start on beta blockers (e.g. bispropolol) or non-dihydropyridine calcium-channel blocker (e.g. verapamil) or increase the dosages.

Discuss cardiovascular disease risk factor modification

37
Q

How can a patient’s risk of bleeding be assesed before adminsitering aspirin or anticoagulants (e.g. fondaprinux)?

A

HAS-BLED score

38
Q

Administraton of aspirin and fondaprinux/PY2Y12 inhibitor in patients suspected of unstable angina is known as?

A

Dual anti-platelet therapy

39
Q

What tool can be used to predict prognosis for patients with acute coronary syndrome?

A

GRACE score

40
Q

What is considered low risk and intermediate/high risk based on GRACE scores?

A

Low risk is 6 month mortality less than or 3%

Intermediate/High risk is 6 month mortality greater than 3%

41
Q

What are 2 complications that can occur when treating patients with unstable angina?

A

Bleeding

Thrombocytopenia

42
Q

What are 2 complications that can arise in patients with unstable angina?

A

Congestive heart failure (Chronic ongoing ischaemia can cause myocardial damage overtime)

Ventricular arrythmias (tacchycardia and fibrilations)

Year 3: Cardiovascular (30 decks)

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