Stable angina Flashcards
Angina definition
Angina refers to classic cardiac pain that is felt when there is a reduction in blood supply to the heart.
What is stable angina
From exertion and physical activity
Usually relieved by GTN spray
Also calcium channel blockers and beta blockers for long term
Dont use beta blockers for severe asthma
For someone who has heart failure before use non rate limiting CCBs and beta blockers
Non - rate limiting CCB - amlodopine
Epidemiology of angina
- Angina is a common presenting complaint, with over 500,000 new cases of angina occurring in the US every year.
- M>F
- More common with increasing age
Non - modifiable RFs
- Age
- Male gender
- FH
Modifiable RFs
- HT
- Diabetes
- Obesity
- Hypercholesterolaemia
- Smoking
- Stress
- Sedentary lifestyle
What is angina caused by?
- Reduced blood flow causing ischaemia to heart muscle - caused chest pain
- Occurs when patient has greater than or equal to 70% stenosis
Stress and rest in agina
- Small opening:the blood that flows through for now is enough 4 heart during rest
- not enough during exercise or stress situations
- metabolic demands arent met during stress for heart muscle - patients experience pain which is resolved with rest
Causes of angina
- Atherosclerosis of one or more of coronary arteries
- Aortic stenosis
- Valvular disease
- Arrhythmias
- Embolus to the coronary artery
- Vasculitis: causing aneurysm
- Anaemia: less O2 is transported to the heart
Signs of angina
- Xanthomas or xanthelasma: suggests hypercholesterolaemia
-
Hypertension
- A risk factor for angina
- Retinopathy may be seen on fundoscopy
- Evidence of peripheral vascular disease: may coexist with ischaemic heart disease
Symptoms of angina
Angina can be precipitated by exertion, heavy meals, cold weather and emotion. Symptoms are usually relieved within 5 minutes by rest or GTN.
- Cardiac-sounding chest pain
- Crushing, left-sided chest pain
- Often radiating to neck, jaw, shoulders and left arm
- Dyspnoea
- Nausea
- Sweating
Primary investigations of angina
- Physical Examination (heart sounds, signs of heart failure, BMI)
- First line:12-lead ECG (ST segment depression) and CT angiography (gold standard)
- Second line:functional imaging (stress echo, or cardiac MRI) if CT angiography is non-diagnostic
- Third line: transcatheter angiography
Characteristic features of angina
- Discomfort to the chest, neck, jaw, shoulders or arms
- Symptoms brought on by exertion
- Symptoms relieved within 5 minutes by rest or glyceryl trinitrate (GTN)
Typical angina has all 3
atypical 2
non-anginal chest pain 1
Symptomatic relief of angina
-
Symptomatic relief
- GTN spray or tablet: vasodilator
- If pain persists for 5 minutes after the first dose, then repeat the dose. If after 5 minutes the pain still remains, then an ambulance should be called
First line (symptomatic relief)
GTN spray
Angina medication
- 1st line: BB or CCB
- 2nd line: BB + CCB
- 3rd line: BB + CCB
- Nitrates
- Ivabradine
- Nicorandil
- Ranolazine
PCI
aballoon is inflated in a stenosed vessel and a stent is placed to ensure the lumen remains open.
Coronary artery bypass graft CABG
involves opening the chest along the sternum (causing a midline sternotomy scar), taking a graft vein from the patient’s leg (usually the great saphenous vein) and sewing it on to the affected coronary artery to bypass the stenosis. Associated with a better overall outcome, however, is associated with greater perioperative risks
Angina prevention
- Lifestyle changes: exercise, dietary alterations, lipid, diabetes and hypertension management, smoking cessation
- Aspirin and astatin
- Angiotensin-converting enzyme inhibitors(ACEi): if the patient has angina and diabetes
Complications of angina
- MI:a plaque may continue growing until the coronary artery is completely obstructed
- Chronic heart failure:the**underlying causes of ischaemic heart disease are also associated with an increased risk of chronic congestive heart failure
- Stroke:atherosclerosis may also develop within the cerebrovascular system
Commonest reason for angina
IHD
Exacerbating factors for angina
- Anaemia
- Hypovolaemia
- Hypervolaemia
- Tachyarrhythmia
- Valvular heart disease
Environmental causes of angina
Exercise
cold weather
heavy meals
emotional stress
What is the physiology of myocardial ischemia?
Myocardial ischemia occurs when there is an imbalance between the heart’s oxygen demand and supply, usually from an increase in demand (eg exercise) accompanied by limitation of supply:
- Impairment of blood flow by proximal arterial stenosis, narrowed coronary artery
- Increased distal resistance eg left ventricular hypertrophy
- Reduced oxygen-carrying capacity of blood eg anemia
What is prinzmental’s angina
very rare – vessesles become narrow with coronary spasm
DDs of chest pains
- Myocardial ischemia
- Pericarditis/ myocarditis
- Pulmonary embolism/ pleurisy
- Chest infection/ pleurisy
- Gastro-oesophageal (reflux, spasm, ulceration)
Treatment options for IHD
Reassure
smoking
Weight
Exercise
diet
Advice for emergency
Medication
Revascularisation
Good investigations to use
- CT coronary angiogram - Good ‘rule-out’ test and at spotting severe disease
- Perfusion MRI - best non invasive test
BB effects on heart
- decreased HR (-ve chronotropic )
- decreased Left ventricle contractility (-ve inotropic)
- Both of these lead to:
- decreased cardiac output > decreased O2 demand
BB SE
Tiredness
Nightmares
Erectile dysfunction
Bradycardia
Who do you never give BBs to
Never give beta blockers to someone with asthma – blocks beta blockers – bronchoconstrictor
Nitrate effects (venodilators)
- Main effect is on venous return – expands venous capacity – reduces pre load on heart – small affect on arterioles
- Dilates coronary arteries
What do CCB
Decrease HR >
Decreased LV contraction and decreased work >
Arteries dilate >
Decreased BP >
Decreased Afterload >
Decreased O2 demand >
Coronary arteries dilate
What are SEs of CCBs
Flushing
Postural hypotension
Swollen ankles
Statins
- HMG CoA Reductase inhibitors
- Reduce manafucture of LDL cholesterol
- Used in CVD
RAAS
Angiotensinogen from liver (Renin from JG apparatus)>
Angiotensin 1 (ACE from lung)> Angiotensin 2 Causes vasoconstriction
Angiotensin 2 > Alodsterone from adrenal cortex > Na+ pump activated (distal renal tubule) > Na+ +H20 retention (kidney) ascending renal tubule
Treatment summary for angina
Immediately GTN Spray
Long term calcium channel blockers and beta blockers
Secondary prevention aspirin, ACE inhibtor, beta blockers clopidogrel
