Stable Angina Flashcards
Define angina
A discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis
Describe what happens in terms of oxygen which can lead to angina.
Mismatch between supply of O2 and metabolites to myocardium and the myocardial demand for them
What is the most common cause of angina?
Coronary atheroma
-> A reduction in coronary artery blood flow to the myocardium
What can cause a reduction in coronary artery blood flow to the myocardium?
Obstructive coronary atheroma (Very common)
Spasm of a portion of coronary artery (Uncommon)
Abnormal coronary flow (Uncommon).
What condition is the pathology behind angina?
Sorry i worder that badly
Pathology- myocardial ischaemia
Symptoms- angina
What happens when BP and HR increase?
Myocardial oxygen demand increases
Give some examples of situations where HR and BP might increase and, in turn, increase the myocardial oxygen demand?
Exercise, anxiety/emotional stress and after a large meal.
Which factors help to produce angina symtoms?
Exertion, cold weather, emotional stress, following heavy meal.
Where is the pain distribution in stable angina?
Over the chest but can radiate down the left arm (or both)
What % of obstruction must there be in the lumen to produce angina symptoms?
70%
In terms of clinically, how can you differentiate angina pain and other types of pain?
Taking a good history and asking all the pain related questions to get a better understanding
Where is the site of pain in angina?
Retrosternal (pain inside the chest)
What is the character of angina pain?
Described often tight band/pressure/heaviness.
What is the radiation of the pain like in angina?
Might radiate into neck and/or into jaw, down arms.
What are some of the aggravating factors of angina?
Exertion
Emotional stress
What are some of the relieving factors of angina?
Rapid improvement with GTN or physical rest.
Describe pain which is unlikely to be angina.
Sharp/‘stabbing’ pain; pleuritic or pericardial.
Worse on deep inspiration
Pinpointed to certain location
It’s important to consider differential diagnosis’ when looking at chest pain as it isn’t always angina/myocardial ischaemia.
What are some other cardiovascular conditions which can cause chest pain?
Aortic dissection (intra-scapular “tearing”), pericarditis
What are some respiratory conditions which can cause chest pain?
Pneumonia, pleurisy, peripheral pulmonary emboli (pleuritic)
What are some musculoskeletal conditions which can cause chest pain?
Cervical disease, costochondritis, muscle spasm or strain
What are some GI conditions which can cause chest pain?
Gastro-oesphageal reflux, oesophageal spasm, peptic ulceration, biliary colic, cholecystitis, pancreatitis
What can be used to define the severity of suspected myocardial ischaemia/angina?
CCS- Canadian Classification of Angina Severity
What does a CCS classification of 1 mean?
Ordinary physical activity does not cause angina, symptoms only on significant exertion.
What does a CCS classification of 2 mean?
Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs.
What does a CCS classification of 3 mean?
Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs.
What does a CCS classification of 4 mean?
Symptoms on any activity, getting washed/dressed causes symptoms.
Will you have angina if you have pain at rest?
No- angina is brought on via exertion or other changes in the environment like sudden coldness
What is the definition for stable angina?
Symptoms present upon activity
List some of the non-modifiable risk factors of coronary artery disease/atherosclerotic cardiovascular disease?
Age, gender, creed, family history & genetic factors.
List some of the modifiable risk factors of coronary artery disease/atherosclerotic cardiovascular disease?
Smoking
Lifestyle- exercise & diet
Control of other medical conditions
Control over which conditions helps to reduce risks of coronary artery disease/atherosclerotic disease?
Diabetes mellitus (glycaemic control reduces CV risk)
Hypertension (BP control reduces CV risk)
Hyperlipidaemia (lowering reduces CV risk)
Some patients with stable angina will not have any symptoms when carrying out a CVS examination but what should you look out for?
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.
Pallor of anaemia.
Tachycardia, tremor, hyper-reflexia of hyperthyroidism.
Ejection systolic murmur, plateau pulse of aortic stenosis
Pansystolic murmur of mitral regurgitation, and
Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema.
btw, I don’t expect you to memorise this but it will be important in terms of clinical too!
Why would you look for tar staining?
To understand the degree and length of smoking
Which investigations would you carry out on someone with suspected stable angina?
Bloods
CXR
ECG
Exercise tolerance test
Myocardial perfusion imaging
Computed tomography (CT) coronary angiography
Which bloods would you take in someone with suspected angina?
Full blood count, lipid profile and fasting glucose; Electrolytes, liver & thyroid tests would be routine.
What test do you carry out during an exercise tolerance test?
An ECG - there will be an ST-segment depression upon exercise in those with angina
What are the limitations to exercise tolerance tests?
Some patients may be elderly and unable to exercise
What must a patient have alongside a ST-segment depression to have angina?
Chest pain upon exercise.
Discuss what happens in myocardial perfusion imaging.
One set of pictures taken
Given radionuclide tracer
Upon exercise/drugs in those who cannot exercise, another set of pictures is taken and the two sets are compared
What are the advantages/disadvantages of myocardial perfusion imaging?
Advantages- Better at detecting CAD, localisation of ischaemia and the areas affected
Disadvantages- expensive, involves radioactivity.
What can cardiac catheterisation/coronary angiography allow for?
Definition of coronary anatomy with sites, distribution and nature of atheromatous disease enables decision over what treatment options are possible.
Where are arterial catheters inserted?
Usually radial artery
In terms of treatment strategies, what is meant by general measures?
They address the atherosclerotic cardiovascular disease risk factors
Give some examples of general measures in terms of treatment.
Treatment/education for the following-
BP, DM, Cholesterol
Lifestyle: physical activity & smoking.
Describe the goal for medical treatment when it comes to angina?
Drugs to reduce disease progression & symptoms
If symptoms are not controlled, what might be considered?
Coronary Artery Bypass Graft
When are statins considered for control of symptoms in patients with angina?
If cholesterol is >3.5mmol/L
What do statins do?
Reduce LDL-cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS.
When would ACE inhibitors be considered for control of angina symptoms?
If increased CV risk and atheroma
What do ACE inhibtors do?
Stabilise endothelium and also reduce plaque rupture
What does aspirin do?
May not directly affect plaque but does protect endothelium and reduces of platelet activation/aggregation.
What would you give as an alternative to aspirin if there was an intolerance?
Clopidogrel
Which groups of medication can reduce HR to <60bpm?
Beta blockers, calcium channel blockers, Ik channel blockers
What is the aim for antianginal medications?
Reduce myocardial oxygen demand on activity.
Why might a patient take calcium channel blockers instead of beta blockers?
If they are highly asthmatic
What would peripherally acting calcium channel blockers do?
Produce vasocontraction
What will nitrates do?
Also produce vasoconstriction
What is one of the main side-effects of nitrates?
Headaches
Which medications are often used alongside beta blockers and central calcium channel blockers?
Periphery calcium channel blockers
Nitrates
Potassium channel blockers
For patients who are still having symptoms which are affecting their lifestyles, what option may be considered?
Coronary revascularization
What are two treatment options for coronary revascularization?
CABG
PCI (percutaneous coronary intervention)
Which is simpler- CABG or percutaneous coronary intervention?
Percutaneous coronary intervention
Describe briefly what happens in a percutaneous coronary intervention.
Patient has local anaesthetic
Needle punctures radial artery- balloon stent inserted
Can squeeze atheromatous material into vessel wall and leave a stent.
What medication do patients need to be on if there is a stent used?
Antiplatelet medication to stop arterial thrombosis
Which two specific drugs must a patient take together if they have had a stent?
Aspirin and clopidogrel
Who might get a CABG?
Patients who have multi-vessel coronary disease.
What type of medication do patients who have had a CABG need to be on?
Similarly with percutaneous coronary intervention, patients will need to take antiplatelet drugs
