SIHD & Angina - Presentation

Question 1

What is stable angina?

Answer 1

Constricting chest pain with or without radiation to left arm/jaw. Stable when it is relived with GTN or rest.

Question 2

Outline the pathophysiology of angina.

Answer 2

• mismatch between O2 supply/demand to myocardium
• main cause is atheroma in the coronary arteries
• less commonly: artery spasm, arteritis
• myocardial ischaemia leads to symptoms of angina

Question 3

What are some precipitants of angina?

4

Answer 3

• exercise
• cold weather
• emotional stress
• heavy meal

Question 4

Stable angina becomes symptomatic usually when obstructive plaque (atheroma) obstructs ____ of the artery lumen.

Answer 4

> 70%

Question 5

What important things should be asked in a patient Hx?

5

Answer 5

• site of pain (retrosternal)
• radiation (arm, jaw)
• characteristic (tight band, pressure, heaviness)
• exacerbating factors (GTN, rest)
• aggravating factors (exercise)

Question 6

What features point to something other than angina?

4

Answer 6

• sharp/stabbing pain (pleuritic, pericardial)
• very localised, pin point
• no pattern to pain (rest)
• onset (not after exercise)

Question 7

Outline some differential diagnosis for different systems.

Answer 7

CVS: aortic dissection, pericarditis

Resp: pleurisy, pneumonia

MSK: costochondritis

GI: reflux, peptic ulceration

Question 8

In what patients might myocardial ischaemia result in symptoms other than chest pain/angina?

Answer 8

diabetics/elderly

Question 9

Outline non-modifiable risk factors.

4

Answer 9

Age
gender
family history
genetic factors

Question 10

Outline modifiable risk factors.

5

Answer 10

• Smoking
• Lifestyle - exercise & diet
• Diabetes mellitus (glycaemic control reduces CV risk)
• Hypertension (BP control reduces CV risk)
• Hyperlipidaemia (lowering reduces CV risk)

Question 11

What are clinical signs of stable angina?

6

Answer 11

• Tar stains on fingers
• Obesity (centripedal)
• Xanthalasma and corneal arcus (hypercholesterolaemia)
• Hypertension
• Abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses.
• Diabetic retinopathy, hypertensive retinopathy on fundoscopy.

Question 12

What are some signs of exacerbating or associated conditions?

5

Answer 12

• Pallor of anaemia
• Tachycardia, tremor, hyper-reflexia of hyperthyroidism
• Ejection systolic murmur, plateau pulse of aortic stenosis
• Pansystolic murmur of MR
• Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema.

Question 13

What investigations aid in diagnosing angina?

4

Answer 13

• Hx/exam
• Bloods
• CXR
• ECG (+/- ETT)

Question 14

What blood tests would be carried out?

Answer 14

FBC
UEs
lipid profile
HbA1c/fasting glucose
LFTs
TFT

Question 15

What would a CXR help rule out or identify?

Answer 15

pulmonary oedema

Question 16

What might be picked up on an ECG?

2

hint: ACS

Answer 16

• pathological Q-waves (previous MI)

- lateral ST depression (LVH)

Question 17

What is considered the gold standard diagnostic investigation?

Answer 17

CT coronary angiography

Question 18

OutliSne medical therapy for stable angina.

Answer 18

Immediate relief:

• GTN spray
• K+ blockers

Long term relief:

• B-blocker
• CCB
• long-acting nitrites (e.g. ivabradine)

Secondary prevention (AAAA)

• atorvostatin
• aspirin
• ACEi
• a B-blocker

Question 19

What does a statin do?

Answer 19

Reduce LDL-cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS.

Question 20

What are the surgical treatment strategies?

Answer 20

• Percutaneous coronary intervention (PCI)

- CABG