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Cardiovascular System > Stable Angina > Flashcards

Stable Angina Flashcards

1
Q

What is angina pectoris?

A

Chest pain

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2
Q

What is myocardial ischaemia?

A

A mismatch in the supply of O2 and metabolite to the myocardium and the demand of for them

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3
Q

What are the two general causes for myocardial ischaemia?

A

Interruption of blood flow

Inadequate blood flow

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4
Q

What is a common cause of angina?

A

Obstructive coronary atheroma

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5
Q

What are two uncommon causes?

A 
Coronary artery spasm 
Coronary inflammation (arteritis)
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6
Q

How can anaemia cause angina?

A

Reduces the transport, so not as much O2 delivered to myocardium

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7
Q

In what pathological conditions would O2 demand be increase, and so have the capacity to cause angina?

A

Left ventricular hypertrophy (LVH)

Thyrotoxis (hyperthyroidism)

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8
Q

What can cause LVH?

A

Persistent hypertension
Significant aortic stenosis
Hypertrophic cardiomyopathy

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9
Q

What is stable angina?

A

Angina pectoris, a predictable pattern of chest pain

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10
Q

What situations does stable angina arise?

A

Where HR and BP rise as there is greater myocardial oxygen demand
I.e. exercise, anxiety, cold weather, emotional stress, after a large meal

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11
Q

What are the characteristic of chest pain in stable angina?

A 
Restrosternal pain
Tight band/pressure
Radiation into neck, jaw, down arms 
Aggravating: with exertion, emotional stress 
Improved by GTN or rest
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12
Q

If chest pain is associated with body movements, i.e. leaning forward improves pain and leaning back makes it worse, is it likely to be stable angina?

A

No

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13
Q

If chest pain is stabbing/sharp, is it likely to be angina?

A

No - pleuritic or pericardial

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14
Q

If chest pain is localised, is it likely to be angina?

A

No

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15
Q

If there is no pattern to chest pain, is it likely to be angina?

A

No

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16
Q

If chest pain begins some time after exercise, is it likely to be angina?

A

No

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17
Q

If chest pain lasts for hours, is it likely to be angina?

A

No

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18
Q

List differential diagnoses for chest pain: CVD causes

A

Aortic dissection

Pericarditis

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19
Q

List differential diagnoses for chest pain: respiratory causes

A

Pneumonia
Pleurisy
Peripheral pulmonary emboli

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20
Q

List differential diagnoses for chest pain: musculoskeletal

A

Cervical disease
Costochondritis
Muscle spasm
Strain

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21
Q

List differential diagnoses for chest pain: GI causes

A 
Gastro-oesophageal reflux 
Oesophageal spasm
Peptic ulceration 
Biliary colic 
Cholecystitis 
Pancreatitis
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22
Q

What are other symptoms of myocardial ischaemia on exertion other than chest pain?

A

Breathlessness
Excessive fatigue
Near syncope

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23
Q

What classification can be used to determine severity of angina?

A

Canadian classification of angina severity (CCS)

24
Q

Define the classification of severity in the CCS

A

I - symptoms only on exertion
II - symptoms walking > 1 flight of stairs
III - symptoms walking 1 flight of stairs
IV - symptoms on any activity

25
Q

Name modifiable risk factors

A 
Smoking
Lifestyle - exercise & diet 
Diabetes mellitus 
Hypertension 
Hyperlipidaemia
26
Q

Non-modifiable risk factors

A 
Age 
Gender
Race - south asians (high diabetes rate)
FH 
Genetic factors
27
Q

Signs of stable angina

A 
Tar staining on fingers 
Obesity 
Corneal scrubs 
Xanthalasma 
Hypertension 
Abdominal aortic aneurysm arterial bruits
Absent or reduced peripheral pulses
Diabetic retinopathy, hypertensive retinopathy
28
Q

Signs of exacerbating conditions:

A

Pallor of anaemia
Tachycardia
Tremor
Ejection systolic murmur
Plateau pulse of aortic stenosis
Pansystolic murmur of mitral regurgitation
HF: basal crackles, elevated JVP, peripheral oedema

29
Q

What is a plateau pulse

A

The time taken to reach the peak is prolonged and the entire wave is flattened and of small amplitude

In aortic stenosis, the rate of ejection of blood into the aorta is decreased so that the duration of the ejection is prolonged. The amplitude of the pulse is diminished as a consequence

30
Q

List the investigations used

A 
FBC 
Lipid profile 
Fasting glucose 
U+E
LFT 
TFT  
CXR 
ECG 
Exercise Tolerance test 
Myocardial Perfusion Imaging
31
Q

Why use CXR to investigate?

A

Can show other causes of chest pain and show pulmonary oedema

32
Q

Why use ECG to investigate?

A

Evidence of:
Prior MI (pathological Q waves)
LVH - ST segment depression

33
Q

What test can confirm diagnosis of angina?

A

Exercise tolerance test

Shows typical symptoms and ST-segment depression

34
Q

Why use myocardial perfusion imaging?

A

Better than ETT in showing coronary artery disease, localisation of ischameia and assessing size of area affected
Involves radiotherapy, use when ETT not available

35
Q

How is the ischaemia induced in myocardial perfusion imaging?

A

Exercise
Pharmacological stress: adenosine, dipyridamole or dobutamine

Radionuclide tracer injected at peak stress

36
Q

How to determine if ischaemia is present?

A

Take to imagine: one at rest and at peak stress and compare

Tracer seen at rest but not at stress = ischaemia
Tracer not seen at all = infarction

37
Q

What investigation can be used to diagnose stable angina?

A

CT coronary angiography

38
Q

When to carry out a CT coronary angiography

A 
Strongly positive ETT 
Angina with no benefit from therapy
Diagnosis unclear after non-invasive tests 
Young cardiac patients 
Occupation or lifestyle risks
39
Q

Benefit of using CT coronary angiography/cardiac catheterisation?

A

Defines coronary anatomy, nature of atheromatous disease and helps decision over what treatment is possible:

Just meds or PCI or CABG

40
Q

Features of CT angiography

A

Under local anaesthetic
Cannula inserted to femoral or radial artery
Coronary catheter passes to aortic root then coronary aa.
Radio-opaque contrast injected down aa. and seen on Xray

41
Q

General measure taken for treatment of stable angina

A 
Adress risk factors:
BP
Diabetes mellitus 
Cholesterol 
Lifestyle
42
Q

What revascularisation treatment is there and when to use them?

A

Percutaneous coronary intervention (PCI)

Coronary artery bypass (CABG)

43
Q

What drugs are used to stop the disease progression in stable angina?

A

Statins
ACEi
Aspirin

44
Q

Effect of statins

A

If total cholesterol > 3.5mmol/L

Reduce LDL deposition in atheroma and stabilise atheroma by reducing risk of plaque rupture and ACS

45
Q

Effect of ACEi

A

Stabilise endothelium and reduce risk of plaque rupture

46
Q

Effect of aspirin

A

75mg or clopidogrel if intolerant

Protect endothelium and reduces risk of platelet aggregation

47
Q

What drugs are used for relief of symptoms in stable angina?

A

B blockers
Ca channel blockers
Ik channel blockers
Nitrates

Trying to achieve HR < 60 ppm

48
Q

Effect of B blockers

A

Reduce myocardial work and have anti-arhythmic effects

49
Q

Effect of CCB drugs

A

Produces vasodilation
Diltiazem
Amlodipine

50
Q

Effect of Ik channel blockers

A

Reduces SA node rate (control HR)

I.e. ivabridine

51
Q

Effect of nitrates

A

Rapidly acting GTN spray for immediate use

52
Q

Mechanism of percutaneous coronary intervention used to treat angina

A

Similar approach to cardiac catheter, but insert a wguidewire into the stenotic lesion to squash the atheromatous plaque into walls with balloon and stent

53
Q

What drugs are taken after PCI and why?

A

Aspirin and clopidogrel

To allow endothelium to cover stent so that it is no longer seen are a foreign body with risk of thrombosis

54
Q

What type of patient will receive a prognostic benefit from CABG?

A

> 70% stenosis of L main stem artery
Proximal three-vessel coronary artery disease
Two vessel coronary artery disease with stenosis of LAD and ejection fraction < 50%

55
Q

Mechanism of CABG

A

Long saphenous vein harvested then reversed and used as coronary artery bypass graft

Cardiovascular System (37 decks)

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