Stable Angina Flashcards
What is angina?
Discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis
Why does angina happen?
Mismatch between supply of oxygen and metabolites to the myocardium and the myocardial demand for them
What causes angina?
Obstructive coronary atheroma
Coronary artery spasm
Coronary inflammation
What is the most common cause of angina?
Obstructive coronary atheroma
What are the very unlikely causes of angina?
Reduced oxygen transport
Pathologically increased myocardial oxygen demand
What can cause angina because of reduced oxygen transport?
Anaemia
What can cause angina because of increased myocardial oxygen demand?
LV hypertrophy
Thyrotoxicosis
Why does hypertrophy cause angina?
Because there is more tissue to supply blood to but not enough blood so there is ischaemia which causes pain
What can cause LV hypertrophy?
Hypertension
Aortic stenosis
Hypertrophic cardiomyopathy
When does myocardial oxygen demand increase?
Increased heart rate
Increased blood pressure
Why does angina happen?
Because of myocardial ischaemia
Where is the typical distribution of pain or discomfort with angina?
On the left top side of the chest and going down the medial part of the left arm
What is the key characteristic of stable angina?
It happens on exertion and goes away after rest
In the blood vessels what causes stable angina?
Obstructive plaque that covers 70% or more of the lumen
When there is spontaneous rupture of a plaque and local thrombosis with a degree of occlusion what is this called?
Acute coronary syndrome
What is the typical character of pain associated with angina?
Tight band
Pressure
Heaviness
Where are the radiation sites for angina pain?
Neck
Jaw
Down arms
What aggravates stable angina?
Exertion
Emotional stress
What improves angina rapidly?
GTN
Physical rest
What characteristics make angina less likely?
Sharp/stabbing pain Associated with body movement or respiration Very localised Superficial No pattern to pain Often occurring at rest Begins after exercise Last for hours
What symptoms can myocardial ischaemia present as without angina?
Breathless on exertion
Excessive fatigue on exertion
Near syncope on exertion
Who is more likely to present with myocardial ischaemia without angina?
Elderly
Diabetes mellitus
What are the risk factors for coronary artery disease?
Age Gender Family history Genetic factors Smoking Lifestyle Diabetes mellitus Hypertension Hyperlipidaemia
What should you look for on examination of stable angina?
Tar staining Obesity Xanthalasma Corneal Marcus Hypertension Abdominal aortic aneurysm atrial bruits, absent or reduced peripheral pulses Diabetic retinopathy
What are some exacerbating or associated conditions to stable angina?
Anaemia Tachycardia Aortic stenosis Hyperthyroidism Mitral regurgitation Heart failure
What are you looking for in anaemia?
Pallor
What are you looking for in hyperthyroidism?
Tachycardia
Tremor
Hyper-reflexia
What are you looking for in aortic stenosis?
Ejection systolic murmur
What are the signs of heart failure?
Basal crackles
Elevated JVP
Peripheral oedema
What investigations can be done for stable angina?
Full blood count Lipid profile Fasting glucose Electrolytes Liver function tests Thyroid function tests Chest x-ray Electrocardiogram Exercise tolerance test Myocardial perfusion imaging CT coronary angiography Coronary angiography
What are the treatment strategies for stable angina?
Address risk factors
Drugs to reduce disease progression and symptoms
PCI
CABG
What is the medical treatment for disease progression?
Statins
ACE inhibitors
Aspirin
What affect do statins have?
Reduces LDL-cholesterol deposition in atheroma so stabilises them reducing plaque rupture and ACS
What affect do ACE inhibitors have?
Stabilises endothelium and reduces plaque rupture
What affect does Aspirin have?
Protects endothelium and reduces platelet activation
What is the medical treatment for relief of symptoms?
Beta blockers Calcium channel blockers Ik channel blockers Nitrates Potassium channel blockers
What do calcium channel blockers do?
Produce vasodilation
What do Nitrates do?
Produce vasodilation
What do beta blockers do?
Reduce myocardial work and have anti-arrhythmic effects
What is PCI?
Percutaneous coronary intervention such as coronary angioplasty and stenting. Squashes plaque into walls with balloon and stent
What is CABG?
Coronary artery bypass surgery is often the best option for stable angina but is significantly more risky than PCI
