SIHD and Angina Flashcards
what does SIHD stand for
stable ischemic heart disease
what are the 3 golden things to remember about angina
stable angina comes on almost exclusively on exertion
stable angina more common in people with high CV risk
treatment is symptomatic (treating the symptoms - felling better), However disease modification effects prognosis
what is the definition of angina
literally pain - but adopted to mean chest pain (myocardial ischemia without necrosis)
what causes the chest pain (myocardial ischemia)
a mis-match between O2 supply and demand
what are causes of stable angina (remember - myocardial ischemia) - how common are they
obstructive coronary atheroma CORONARY STENOSIS - v. common
coronary artery spasm - uncommon
coronary inflammation/ arteritis - v. rare
Anaemia - have to be very severally anaemic
or due LVH (left ventricular hypertrophy) and having a lack of O2 to supply it
when does myocardial O2 demand increase - increased HR and BP
exercise, cold weather, anxiety/emotional and after a large meal
how is angina diagnosed
by the HISTORY
what should be red flags for angina in the history
S - site - retrosternal (front of chest)
O - onset - exertion
C - character - tight band, pressure
R - radiation - chest mainly, maybe down the left arm
what happens to someone with angina when they rest or take GTN
a rapid improvement in the chest pain/ tightness
what are the nonmodifiable risk factors for angina
old age, male, family history, genetic factors
what are the modifiable risk factors for angina
smoking
lifestyle - exercise and diet
control of conditions
diabetes mellitus
hypertension
hyperlipidaemia
what is GTN
a smooth muscle dilator
what must you always do to people with chest pain
you must examine people with chest pain to rule out more sever conditions
what is a fairly useful test for finding the underlying cause of the angina
full blood count and lipid profile
what are the 3 main ways to test and confirm it is angina
reproduce symptoms - exercise test - ST depression
demonstrate ischemia
demonstrated dysfunction
both done by CT scan or invasive angiogram (can lead to thrombus)
what are the 3 effects of the treatments
disease modification to improve prognosis
treating the symptoms
surgery
what are the 3 treatment strategies
addressing risk factors
medicines
revascularisation - surgery
when is revascularisation (surgery) undertaken
when the symptoms are not controlled
what medicines influence disease progression - when would they be used
statins - if high cholesterol
ACE inhibitors - if high CV risk and atheroma
aspirin - protects epithelium - put on in genera
what medicines can be used for symptom relief
beta blockers
nitrates - GTN - vasodilation
Ca2+ channel blockers - vasodilation
in relation to angina what would statins be used for
reduce LDL cholesterol deposition in atheroma
stabilise atheroma
and can lead to stabilisation/ regression
Disease mod
in relation to angina what would ACE inhibitors be used for
lowers B
if increased CV risk and atheroma
stabilises endothelium and also reduces plaque rupture
in relation to angina what would aspirin be used for
may not directly effect plaque
but stops platelet aggregation
protects endothelium
in relation to angina what would beta blockers be used for
Reduced myocardial work and have anti-arrhythmic effects
in relation to angina what would Ca2+ channel blockers be used for
produce vasodilation
what would nitrates be used for angina
GTN (Glycerine trinitrate)
Used as short or prolonged acting patches or tablets to increase vasodilation
what are the revascularisation options
PCI - percutaneous coronary intervention
coronary artery bypass surgery
what is PCI - is it effective
squash atheroma with balloon, stent to keep the vessel open
it is effective for symptom relief but no effect in disease modification
what is coronary artery bypass
putting in vessels from elsewhere bypassing the effected vessels
a more extensive surgery
but produces better long term effects
what are the acute coronary syndromes
MI - STEMI, NSTEMI
unstable angina pectoris
what are the stable coronary artery diseases
angina pectoris
silent ischaemia
what does Stable coronary artery disease (SCAD) result as
a mismatch between myocardial blood/ oxygen supply and demand
how do drugs correct the supply and demand imbalance
decrease O2 demand
-reduce HR
- reduce myocardial contractility
- reduced afterload
increase the O2 supply
what are the rate limiting drugs
decrease demand
beta-adrenoceptor antagonists (beta blockers)
ivabradine
calcium channel blockers
what are the vasodilators (increase supply)
calcium channel blockers
nitrates
other than vasodilators and rate limiting drugs what are othe drug therapyies used for stable ischemic Heard disease
potassium channel openers
aspirin/cpopidogrel/tiagagrelor
cholesterol loweerinf agegnts
what are beta blockers
Block the sympathetic system as reversible antagonists of the beta 1 and 2 receptors
decrease HR, contractility, CO and decrease BP
increase exercise threshold before angina
what are examples of beta blockers
bisoprolol, atenolol
what can sudden stopping of beta blockers do
may precipitate myocardial infarction
what are the contraindications for beta blockers
asthma
PVD (peripheral vascular disease)
heart failure
bradycardia
what are some adverse reactions of beta blockers
tiredness
impotence
bradycardia
bronchospasms
what are some drug-drug interactions of beta blockers
hypertensive agents
other rate limiting drugs
cardiac failure when used negatively with inotropic agents
what are some examples of calcium channel blockers
dil-ti-a-zem
ver-ap-a-mil
am-lod-i-pine
ni-fed-i-pine
what do calcium chanel blockers do
prevent calcium influx into myocytes/smooth muscle around arteries
BLOCKS L-TYPE CALCIUM CHANNELS
what is a example of a rate limiting Calcium channel blocker (what do they do)
diltiazem
verapamil
reduce HR and contractilty
what are examples of vasodilation calcium channel blockers (what do they do)
amlodipine
NIFEDIPINE
reduce vascular tone and reduce afterload
what are the contraindications for calcium
NEVER USE NIFEDIPINE IMMEDIATE RELEASE - contributes to acute MI/stroke
what are some adverse drug reactions of calcium channel blockers
ankle oedema - and 20% of patients don’t respond to diuretics
headache
flushing
palpitation
what is an example of nitrovasodilators
GTN
what does GTN stand for
glyceryl trinitrate
what do nitrovasodilators do
release NO which stimulated cGMP which produced smooth muscle relaxioant
reduces preload and afterload
what are the uses of GTN
rapid angina treatment
prophylactic
avoid first pass metabolism
when are IV nitrates used
along with heparin in the treatment of unstable angina
what are the problems with nitrovasodilator
Tolerance to the effects of nitrate therapy can develop rapidly
what are adrevrs drug reactions of GTN
hypotension
GTN syncope
what is ivabradine
selective sinus node If channel inhibitor
Slows the diastolic depolarisation slope of the SA-node
reduced HR in turn myocardial O2 demand
what is nicorandil
preconditioning drug
opens up ATP sensitive K+ channels - cardioprotrctive effect with out ischemia
Low Dose Aspirin is the most common cause of what
admission with a GI bleed
what is the prescribe 1st line treatment of angina
short acting nitrates
plus
beta blocker/ and or CCB
what is the preventative treatment for stable coronary artery disease
lifestyle changes
risk factor control
aspirin
statins
ACE inhibitor is other cardiac conditions are present
what are 2nd line drugs for angina relief
ivabradine or
niocorandil or
long acting nitrates
what are 2nd line drugs for angina relief
ivabradine or
niocorandil or
long acting nitrates
what is aspirin
Aspirin is a potent inhibitor of platelet thromboxane production
what is thromboxane
stimulates platelet aggregation and vasoconstriction
when can aspirin be used
Use for the symptomatic treatment of chronic stable angina in adults with normal sinus rhythm and heart rate ≥ 70 bpm.
All patients with stable angina should be
consider ACE inhibitors
if atherosclerotic
consider long-term aspirin and statin therapy
what is a common example of cholestrolo loweing agents
simvastatin
