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Cardiovascular > Stable Angina > Flashcards

Stable Angina Flashcards

1
Q

What is the definition of angina?

A

A discomfort in the chest or/and adjacent areas associated with myocardial ischaemia but without myocardial necrosis

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2
Q

Explain the pathophysiology of myocardial ischaemia

A

A reduction in coronary artery blood flow to the myocardium caused by obstructive atheroma, spasm of coronary artery or abnormal flow

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3
Q

What are some more uncommon causes for myocardial ischaemia?

A

Reduced O2 transport - anaemia
Increased myocardial O2 demand - left ventricular hypertension
Thyrotoxicosis - whole body increased O2 demand

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4
Q

What is the most common cause for angina?

A

Coronary atheroma
Increased myocardial O2 demand as blood flow is obstructed leads to myocardial ischaemia
Oxygen demand increases in situations of HR and BP rise like exercise or stress

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5
Q

What is stable angina?

A

Typical distribution of pain or discomfort
Precipitated by excess myocardial O2 demand - exercise, cold air, stress, following a heavy meal

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6
Q

When is stable angina seen - due to obstruction?

A

When obstructive plaque is more than 70% of artery as atherosclerosis is a progressive process

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7
Q

What is acute coronary syndromes seen?

A

When there is spontaneous rupture and local thrombosis with degree of occlusion

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8
Q

What characteristics of patients pain show stable angina signs?

A

Site of pain - retrosternal
Character of pain - often tight pressure or heaviness
Radiation site - neck, jaw, arms
Aggravation - on exertion, stress, or any relieving factors like improvement with rest

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9
Q

What are factors that make angina less likely?

A

Sharp stabbing pain, pericardial pain, localised, associated with inspiration, superficial, no pattern to pain, lasts for long time and begins after some time from exercise

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10
Q

What are some differential diagnoses for chest pain?

A

Cardiovascular causes - aortic dissection, pericarditis
Resp. - pneumonia, pleurisy, peripheral pulmonary emboli
Musculoskeletal - cervical disease, muscle spasm or strain
GI causes - oesophageal spasm, ulceration, pancreatitis

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11
Q

What are some signs of myocardial ischaemia where there is no chest pain?

A

Breathlessness on exertion
Excessive fatigue on exertion
Near syncope on exertion
This is seen in the elderly or diabetes as reduced pain sensation

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12
Q

How is severity of stable angina measured?

A

Canadian classification of angina severity (CCS0
I - least symptoms
IV - most symptoms like on any activity

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13
Q

What are some non-modifiable risk factors for stable angina?

A

Age, gender, creed, family history, and genetic factors

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14
Q

What are some modifiable factors for stable angina?

A

Smoking, lifestyle, diet, diabetes mellitus, hypertension and hyperlipidaemia

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15
Q

What are some examinational findings that can show other condition?

A

Tar staining
Obesity
Xanthalasma and corneal arcus - hypercholesterolaemia
Hypertension
Abdominal aortic aneurysm bruits, absent or reduced peripheral pulses
Diabetic retinopathy or hypertensive retinopathy

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16
Q

What blood examinations should be carried out for stable angina?

A

FBC, lipid profile, fasting glucose, electrolytes, liver and thyroid tests

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17
Q

What is CXR used for in stable angina?

A

Show other causes for chest pain
Can show pulmonary oedema

18
Q

What will an electrocardiogram show in patient with stable angina?

A

Normal in over 50% of cases
May be evidence of prior myocardial infarction - pathological Q waves
May be evidence of left ventricular hypertrophy - lateral ST segment depression or strain pattern

19
Q

What does exercise tolerance test show for a patient with stable angina?

A

Often confirms angina diagnosis - produces CV stress
Shows typical symptoms and ST-segment depression for a positive test
Evaluated with an ECG

20
Q

Explain myocardial perfusion imaging

A

Superior to ETT in detection of CAD, localisation of ischaemia and assessing size of area affected
Involves radioactivity
If cant exercise then pharmacological stress is used

21
Q

What is given to produce pharmacological stress?

A

Adenosine
Dipyridamole
Dobutamine

22
Q

How does myocardial perfusion imaging work?

A

Radionuclide tracer is injected at peak stress on one occasion and image obtained and rest on another so compare
Normal myocardium take up tracer

23
Q

What are the results of a myocardial perfusion imaging?

A

Tracer is seen at rest but not after stress = ischaemia
Tracer neither seen at rest or after stress = infarction

24
Q

Describe an ECHO test?

A

US looking at cardiac structure - particular left articular myocardium
Can be done at rest using a stressor
See if area has reduced contractibility on stress - reduced blood flow so MI

25
Q

What doe a CT look for?

A

Can check for coronary heart disease
Non-invasive

26
Q

When is invasive angiogram given?

A

Early or strongly positive ETT
Angina refractory to medical therapy
Diagnosis not clear
Young cardiac patient due to work/life effects
Occupation or lifestyle with risk

27
Q

What are the treatment options?

A

Medication alone
PCI - percutaneous coronary intervention which involves angioplasty and stenting or bypass graft surgery

28
Q

Explain cardiac catheterisation/coronary angioplasty?

A

Almost always done under local anaesthetic
Arterial cannula inserted into femoral or radial artery
Passed to aortic root and introduced to ostium of coronary arteries
Radio-oblique contrast injected down coronary arteries and visualised on X-ray

29
Q

What is the nature of coronary angiogram?

A

Eccentric
Views from different planes

30
Q

What are some general treatment measures?

A

Address ASCVD risk factors - BP, DM, cholesterol, lifestyle, smoking…

31
Q

What are medical treatment options?

A

Statins, ACE inhibitors and Aspirin
Influencing disease progression

32
Q

What are some revascularisation treatments?

A

Percutaneous coronary intervention and Coronary artery bypass grafting

33
Q

What do statins do?

A

Reduce LDL-cholesterol in atheroma and also stabilise to avoid plaque rupture and ACS
Consider if total cholesterol is > 3.5mmol/l

34
Q

What does an ACE inhibitor do?

A

Stabilise endothelium and also reduce plaque rupture
Consider if increased CV risk and atheroma

35
Q

What does aspirin do?

A

Protects endothelium and reduced platelet aggravation/ activation
75mg or Clopidogrel if intolerant to aspirin

36
Q

What drugs are given for relief of symptoms?

A

B blockers to reduce myocardial work and anti-arrhythmic effects
Ca2+ channel blockers
Ik channel blockers
All to try achieve resting hr of less than 60

37
Q

What are other drugs which cause vasodilation and relief of symptoms?

A

Ca2+ channel blockers
Nitrates
K+ channel blockers

38
Q

Describe percutaneous transluminal coronary angioplasty and stenting

A

Cross stenotic lesion with guidewire and squash atheroma with balloon and stent
If stent then take aspirin and Clopidogrel together while endothelium covers the stent

39
Q

What does PCI improve?

A

Effective for symptoms but no evidence that it improves prognosis in stable disease
Risk of restenosis is small
Need to continue with modifying medication

40
Q

What are the benefits of Coronary artery bypass surgery?

A

Good lasting affect
Can improve lifespan
More upfront risks than PCI
More intensive and recovery harder
Best option for stable angina

41
Q

Who are the patients that derive prognostic benefit from CABG?

A

> 70% stenosis of left main stem artery
Two vessel coronary artery disease - significant stenosis of proximal left anterior descending coronary artery and who have ejection factor of <50%

42
Q

How is angiography of bypass grafts done?

A

Reversed saphenous vein graft to right coronary artery
Left internal mammary artery to native LAD

Cardiovascular (33 decks)

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