Pathophys and Clinical Presentation of Angina Pectoris

Question 1

Angina Pectoris

Answer 1

Painful myocardial ischemia

Question 2

3 Kinds of Angina Pectoris

Answer 2

Unstable Angina - unstable plaque, oxygen supply
Stable Angina - stable plaque, oxygen demand
Variant Angina - coronary artery focal spasm

Question 3

3 Determinants of Myocardial O2 Demand

Answer 3

HR
Contractility
Wall Stress

Question 4

Wall Stress

Answer 4

(Pressure x Radius)/2(thickness). Only components that vary acutely are pressure and radius, which you can estimate w/ AL (BP) and PL (jugular veins)

Question 5

O2 Extraction and Flow

Answer 5

Constantly extracting max O2, flow is the thing that fluctuates. Flow parallels demand in system with adequate flow reserve

Question 6

Ischemic Threshold

Answer 6

Rate Pressure Product: Systolic BP x HR at presentation of angina. Reflects flow reserve, anything above that get ischemia and supply can’t keep up w/ demand

Question 7

RPP Values

Answer 7

> 20k is high O2 demand so demand/stable ischemia. Lower RPP means no cardiac reserve so situation more critical. Don’t use nitroglycerin bc that drops P more

Question 8

2 Components of Coronary Flow Reserve

Answer 8

Epicardial stenosis and microvascular dilation and shit

Question 9

CAD & Degree of Ischemia =

Answer 9

Endothelial Injury + Microvascular Disease + Epicardial Stenosis

Question 10

3 Criteria for Typical Angina

Answer 10

Retrosternal chest pain
Provoked by exertion/emotion
Relieved by rest/nitroglycerin

Question 11

Atypical Angina

Answer 11

Meets 2 criteria for typical angina

Question 12

Atypical Angina CAD Prevalence

Answer 12

50%. So how to tell? 2 Cardiac enzyme tests 6-8 hrs apart

Question 13

Canadian Classification of Angina

Answer 13

I - extraordinary exertion
II - moderate exertion
III - Mild Exertion
IV - rest

Question 14

NY vs. Canadian Classification

Answer 14

NY for HF, Canadian for Angina

Question 15

3 Types of ST Segment Depressions (& which dangerous)

Answer 15

Upsloping - maybe

Horizontal or downsloping - better chance of CAD and more serious

Question 16

Variant Angina

Answer 16

Coronary artery spasm from focal vasoconstriction. Paradoxical and unprovoked w/ little or no plaque. Can provoke w/ some med to test

Question 17

Acute and Chronic Variant Angina Treatments

Answer 17

Acute: Nglycerin
Chronic: Ca channel block
Smooth muscle dilation

Question 18

3 Cocaine Induced Ischemia Mechs (& which one don’t give BBs for)

Answer 18

Increased O2 demand w/ limited supply
Vasoconstriction - don’t give BBs because alpha Rs left so can get more spasm
Accelerated Atherosclerosis/Thrombosis/Plaque Rupture

Question 19

4 Situations Where Don’t Give BBs

Answer 19

Acute systolic HF
Active Wheezing
High Grade Arrhythmias Causing Bradycardia
Cocaine Induced Vasoconstriction?

Question 20

3 Categories of Acute Coronary Syndrome (& how to distinguish)

Answer 20

Unstable Angina (also has ST depression)
Non-STEMI - (tell from unstable angina via troponin, cardiac enzymes)
STEMI - obvious

Question 21

ST Dep vs. Elevation and Anatomical Location

Answer 21

Depression not anatomically specific, elevation is

Question 22

4 Clinical Syndromes of Unstable Angina

Answer 22

Rest Angina - acute coronary insufficiency
New Onset Angina - w/ crescendo pattern, happens first time and person stops activity, pain keeps getting worse so not like stable that relieves on rest
Crescendo Angina
Postinfarction Angina

Question 23

Stable vs. Unstable Angina Treatment (2/4)

Answer 23

Treat both w/ aspirin/nitrates/BBs/Ca blockers, but w/ unstable also need to treat aggressively w/ anti-platelet/heparin

Question 24

Ischemic Cascade (& important points)

Answer 24

Decreased Relation (diastolic dysfunction, S4), systolic dysfunction (S3), filling, ST alterations (so need serial ones bc might not have presented), angina, so angina at end of ischemic cascade

Question 25

Stress Test if Pt Can’t Walk

Answer 25

Chemical stress test idiot

Question 26

When to Treat w/ ACEis

Answer 26

EF<40 (& HTN and shit of course)

Question 27

Timeframe Necessary b/w PDEis and Nitrates

Answer 27

48 hrs. So stop popping all the Viagra Ronak

Question 28

BBs Management of Angina

Answer 28

Reduce O2 demand by reducing HR/contractility/wall tension

Question 29

Ca Channel Blocker Management of Angina

Answer 29

Not used acutely, only cronic