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CVS > Stable Angina > Flashcards

Stable Angina Flashcards

1
Q

What is the definition of angina?

A

Discomfort in chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis

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2
Q

What are the most common ways coronary blood flow to the myocardium is reduced?

A

Obstructive coronary atheroma (Very common)

Coronary artery spasm (Uncommon);

Coronary inflammation/arteritis (Very rare)

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3
Q

What are the uncommon reasons for having stable angina?

A

Uncommonly due to :

  • coronary spasm or artery inflammation
  • Reduced O2 transport (anaemia of any cause)
  • Pathological increase in myocardial O2 demand (LVH - caused by severe hypertension, significant aortic stenosis and hypertrophic cardiomyopathy)
  • Thyrotoxicosis - hypermetabolic state.
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4
Q

What is the effect of coronary atheroma on the onset of exercise?

A

Increased myocardial oxygen demand leads to myocardial ischaemia due to obstructed coronary blood flow - symptoms of angina arise

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5
Q

What situations might cause HR and BP to rise (and therefore myocardial oxygen demand)?

A
  • Exercise
  • anxiety/emotional
  • cold weather
  • stress
  • after large meal
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6
Q

What is angina felt in the chest called?

A

Angina pectoris

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7
Q

What level of obstruction is present in the lumen in stable angina?

A

Obstructive if over 70% of lumen

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8
Q

How should the patient describe the site of the pain?

A

Retrosternal

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9
Q

How should the patient describe character of the pain?

A

tight band/pressure/heaviness

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10
Q

Where can the pain of angina radiate?

A

neck and/or into jaw, down arms

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11
Q

What are the releiving factors for angina?

A

Rest and GTN

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12
Q

When is the pain less likely to be angina?

A
  • Sharp/‘stabbing’ pain; pleuritic or pericardial
  • Associated with body movements or respiration.
  • Very localised; pinpoint site
  • Superficial with/or without tenderness.
  • No pattern to pain, particularly if often occurring at rest.
  • Begins some time after exercise
  • Lasting for hours
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13
Q

What are the differential diagnoses for angina?

Cardiovascular disease

A

Aortic dissection (intra-scapular “tearing”), pericarditis

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14
Q

What are the differential diagnoses for angina?

Respiratory

A

Pneumonia, pleurisy, peripheral pulmonary emboli (pleuritic)

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15
Q

What are the differential diagnoses for angina?

Muscoskeletal

A

Cervical disease, costochondritis, muscle spasm or strain

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16
Q

What are the differential diagnoses for angina?

GI causes

A
  • Gastro-oesphageal reflux
  • oesophageal spasm
  • peptic ulceration
  • biliary colic
  • cholecystitis
  • pancreatitis
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17
Q

What is meant by dissection of aorta?

A

Inner layer of aorta tears

Blood surges through tear

Causes inner and middle layers of aorta to separate (dissect).

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18
Q

Define costochondritis

A

Inflammation of cartilage that connects rib to breastbone (sternum)

Pain caused by costochondritis might mimic that of a heart attack or other heart conditions

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19
Q

What are peptic ulcers?

A

Open sores that develop on inside lining of stomach and upper portion of small intestine

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20
Q

Define biliary colic

A

Pain due to gallstone temporarily blocking bile duct

Pain in right upper part of abdomen and can radiate to shoulder

Pain usually lasts from one to a few hours

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21
Q

Define cholecystitis

A

Inflammation of the Gall bladder

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22
Q

Myocardial ischaemia can occur without chest pain but other symptoms, what are these symptoms?

A

Breathlessness on exertion

Excessive fatigue on exertion for activity undertaken

Near syncope on exertion

More often in elderly or in diabetes mellitus: probably due to reduced pain sensation.

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23
Q

What is the canadian classification for angina severity?

A
  1. Ordinary physical activity does not cause angina, symptoms only on significant exertion.
  2. Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs.
  3. Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs
  4. Symptoms on any activity, getting washed/dressed causes symptoms
24
Q

What are the non-modifiable risk factors for angina?

A
  • Age
  • gender
  • creed
  • family history
  • genetic factors
25
Q

What are the modifiable risk factors for angina?

A
  • Smoking
  • Lifestyle - exercise and diet
  • Diabetes mellitus (glycemic control reduces CV risk)
  • Hypertension (BP control reduces CV risk)
  • Hyperlipidaemia (lowering reduces CV risk)
26
Q

What are typical signs of people with angina?

A
  • Tar stains on fingers
  • Obesity (centripetal, high waist to hip ratio, apple shape)
  • Xanthalasma and corneal arcus (cholesterol deposit in the iris, hypercholesterolaemia)
  • Hypertension
  • Abdominal aortic aneurysm, arterial bruits, absent or reduced peripheral pulses
  • Diabetic retinopathy, hypertensive retinopathy on fundoscopy
27
Q

What are the exacerbating or associated conditions?

A
  • Pallor of anaemia
  • Tachycardia, tremor, hyper-reflexia of hyperthyroidism (overactive reflexes)
  • Ejection systolic murmur, plateau pulse of aortic stenosis
  • Pansystolic murmur of mitral regurgitation
  • Signs of heart failure - basal crackles, elevated JVP, peripheral oedema
28
Q

What are the relevant investigations for angina?

A
  • Bloods
  • CXR
  • Electrocardiogram
  • ETT (Exercise tolerance tests)
  • Myocardial perfusion imaging
  • CT coronary angiography
  • Invasive angiography
29
Q

What do you look out for when measuring bloods?

A

FBC

Lipid profile and fasting glucose

Electrolytes

Liver & thyroid tests are routine

30
Q

Why would you order a chest X-ray for someone with angina?

A

Helps show any other causes of chest pain and can help show pulmonary oedema

31
Q

In what percentage of cases in an electrocardiogram normal for someone with angina?

A

Over 50% of cases

32
Q

What is the significance of pathological Q waves?

A

Prior myocardial infarction

33
Q

How can you tell Left ventricular hypertrophy from an ECG?

A

High voltages, lateral ST-segment depression or “strain pattern”

34
Q

What is a positive test for an ETT?

A

Symptoms of angina arise on exertion

35
Q

What is a negative ETT indicative of?

A

Doesn’t exclude significant coronary atheroma

Shows good prognosis if workload is high

36
Q

Why is moyocardial perfusion imaging superior to ETT in detection of CAD?

A

Better in localising ischaemia and assessing size of affected area

BUT - Expensive, involves radioactivity

37
Q

During myocardial perfusion imaging - how is stress applied to the patient?

A

Excersize or pharmacological stress - nadenosine, dipyridamole or dobutamine

Vasodilators – work on areas that are not affected

38
Q

How are the results from myocardial perfusino imaging interpreted?

A

Comparison of images at rest and after stress

Tracer seen at rest but not after stress = ischaemia

Tracer seen neither rest, or after stress = infarction

39
Q

When would you use invasive angiography?

A
  • Early or strongly positive ETT (suggests multi-vessel ds)
  • Angina refractory to medical therapy
  • Diagnosis not clear after non-invasive tests
  • Young cardiac patients due to work/life effects
  • Occupation or lifestyle with risk e.g. drivers etc
40
Q

What are the different types of percutaneous coronary intervention?

A

Angioplasty and stenting

Coronary bypass graft (CABG) surgery

41
Q

How is cardiac catheterisation / cornary angiography carried out?

A

Under local anaesthetic

Cannula is inserted into the femoral or radial artery

Coronary catheter is passed into the ostium of the coronary arteries.

Radio-opaque contrast injected down coronary arteries and visualised on X-ray.

(Coronary ostium - Opening of coronary arteries at root of aorta

42
Q

Describe the dye used in invasive angiography.

A

Clear, watery, blood compatible, commonly called an X-ray dye

Iodinated - absorbs xrays – picture of lumen and not lumen walls

Iodine is normally clear

43
Q

What are the general measures to control angina?

A

Blood pressure, cholesterol, lifestyle and diabetes mellitus

44
Q

If the symptoms are not controlled after general measures and medical treatment, what are the next steps?

A

Revascularisation in symptoms are not controlled.

Percutaneous coronary intervention (PCI) & coronary artery bypass grafting (CABG)

45
Q

What is the medical treatment that influences disease progression?

A

Statins - for high cholesterol (>3.5 mmol/l.)

Reduce LDL-cholesterol deposition in atheroma, reduce plaque rupture and ACS.

ACE inhibitors - increased CV risk and atheroma

Stabilise endothelium and reduce plaque rupture

Aspirin - 75mg or clopidogrel if intolerant to aspirin

may not directly affect plaque but does protect endothelium and reduces platelet activation/aggregation

46
Q

What is the medical treatment that releives symptoms?

A

Beta blockers - achieve resting hr <60 bpm. Reduced myocardial work and have anti-arrhythmic effects.

Ca2+ channel blockers; achieve resting hr <60 bpm, produce

Central acting eg diltiazem/verapamil if ß-blockers C-I

Peripherally acting dihydropyridines eg amlodipine, felodipine produce vasodilation

Potassium channel blockers - achieve resting hr <60 bpm.

Ivabridine, new medication which reduces sinus node rate

Nitrates: Vasdilation - Used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray for immediate use.

47
Q

What is the main procedure carried out in pericutaneous coronary intervention?

A

Pericutaneous transluminal coronary angioplasty and stenting (now in 95% of procedures)

48
Q

How is the stent applied?

A

Similar process to coronary angiography - ateromaous plaque is squashed with balloon and stent

49
Q

What medicine is used after placement of a stent?

A

Aspirin and clopidogrel - whilst endothelim covers the stent struts until it is no longer seen as a foreign body with associated risk of thrombosis

50
Q

What is PCI effective for?

A

Symptoms but no evidence stating that it improves prognosis

51
Q

What are the risks associated with PCI?

A

Death

MI

Emergency coronary artery bypass grafting

Restenosis

52
Q

What is the best option for treatment of someone with diffuse multi-vessel coronary obstruction

A

Coronary artery bypass surgery

53
Q

How do risks compare between pericutaneous coronary intervention and coronary artery bypass grafting?

A

Upfront risk > PCI

Death - 1.3%

Q-wave MI - 3.9%

(increase with comorbidity)

Good lasting benefit - 80% symptom free in 5 years

CABG - may give prognostic benefit in some subgroups

54
Q

What vein do they normally use in CABG?

A

Long saphenous vein

55
Q

What artery can they use in CABG?

A

Mammary artery

56
Q

Why is the long saphenous vein reversed?

A

So that the valves travel in the correct direction

57
Q

Where is the mammary artery placed?

A

Places the end of the artery beyond the area where the blockage is – usually lasts the lifetime of the patient

CVS (26 decks)

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