Pathophys and Clinical Presentation of Angina Pectoris Flashcards
Angina Pectoris
Painful myocardial ischemia
3 Kinds of Angina Pectoris
Unstable Angina - unstable plaque, oxygen supply
Stable Angina - stable plaque, oxygen demand
Variant Angina - coronary artery focal spasm
3 Determinants of Myocardial O2 Demand
HR
Contractility
Wall Stress
Wall Stress
(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)
O2 Extraction and Flow
Constantly extracting max O2, flow is the thing that fluctuates. Flow parallels demand in system with adequate flow reserve
Ischemic Threshold
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
RPP Values
> 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
2 Components of Coronary Flow Reserve
Epicardial stenosis and microvascular dilation and shit
CAD & Degree of Ischemia =
Endothelial Injury + Microvascular Disease + Epicardial Stenosis
3 Criteria for Typical Angina
Retrosternal chest pain
Provoked by exertion/emotion
Relieved by rest/nitroglycerin
Atypical Angina
Meets 2 criteria for typical angina
Atypical Angina CAD Prevalence
50%. So how to tell? 2 Cardiac enzyme tests 6-8 hrs apart
Canadian Classification of Angina
I - extraordinary exertion
II - moderate exertion
III - Mild Exertion
IV - rest
NY vs. Canadian Classification
NY for HF, Canadian for Angina
3 Types of ST Segment Depressions (& which dangerous)
Upsloping - maybe
Horizontal or downsloping - better chance of CAD and more serious
Variant Angina
Coronary artery spasm from focal vasoconstriction. Paradoxical and unprovoked w/ little or no plaque. Can provoke w/ some med to test
Acute and Chronic Variant Angina Treatments
Acute: Nglycerin
Chronic: Ca channel block
Smooth muscle dilation
3 Cocaine Induced Ischemia Mechs (& which one don’t give BBs for)
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
4 Situations Where Don’t Give BBs
Acute systolic HF
Active Wheezing
High Grade Arrhythmias Causing Bradycardia
Cocaine Induced Vasoconstriction?
3 Categories of Acute Coronary Syndrome (& how to distinguish)
Unstable Angina (also has ST depression)
Non-STEMI - (tell from unstable angina via troponin, cardiac enzymes)
STEMI - obvious
ST Dep vs. Elevation and Anatomical Location
Depression not anatomically specific, elevation is
4 Clinical Syndromes of Unstable Angina
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
Stable vs. Unstable Angina Treatment (2/4)
Treat both w/ aspirin/nitrates/BBs/Ca blockers, but w/ unstable also need to treat aggressively w/ anti-platelet/heparin
Ischemic Cascade (& important points)
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
Stress Test if Pt Can’t Walk
Chemical stress test idiot
When to Treat w/ ACEis
EF<40 (& HTN and shit of course)
Timeframe Necessary b/w PDEis and Nitrates
48 hrs. So stop popping all the Viagra Ronak
BBs Management of Angina
Reduce O2 demand by reducing HR/contractility/wall tension
Ca Channel Blocker Management of Angina
Not used acutely, only cronic
