Stable Angina Flashcards
What causes stable angina
Imbalance between blood supply and demand
Myocardial ischaemia NOT infarction
Narrowing of artery worse on exertion as increased demand
ALWAYS relieved by rest or GTN in contrast to unstable which comes on at rest
What causes decreased blood supply and what worsens
Atherosclerosis >70%
Spasm
Inflammation
Worsens
- Anaemia
- Hypertension
- Tachycardia / AF
- Hyperthyroid
What causes increased oxygen demand
Activity / stress
Increases HR and contractibility
or LVH as requires more O2
What are RF for angina
Age Male Smoking DM Hypertension Hyperlipidaemia Anaemia Hyperthyroid Obesity Exercise Diet
What are the symptoms of angina
Chest pain - heavy / tight / gripping Radiate down T1-T4 (left arm + jaw) Worse exertion / stress SOB on exertion Fatigue on exertion Near syncope N+V / tachycardia / diaphoresis - increased sympa
What makes angina worse
What makes angina better
Worse on exertion / stress
GTN / rest improves
What makes angina unlikely
Sharp stabbing No pattern Comes on after exercise Lasts hours Palpitations Tingling Dizzy
What are signs of associated conditions
Pallor of anaemia Hypertension Tachycardia Systolic murmor - AS / MR Crackles / elevated JVP / oedema = HF
What are signs on examination
Tar staining Obesity Corneal arcus Hypertension AAA Arterial bruit Reduced pulses Retinopathy
What are the differentials for angina
MI / ACS Aortic dissection Pericarditis Pneumonia PE Pneumothorax Epigastric pain / dyspepsia MSK Anxiety
How do you classify severity of angina
1 = only on exertion 2 = slight limitation of activity 3 = marked limitation 4 = symptoms on any activity
When can angina present without pain
Elderly
DM
How do you investigate angina
CVS exam Bloods - FBC - anaemia - U+E - drugs e.g. ACEI - LFT - statin - Lipids - RF - HbA1c and fasting glucose - RF - TFT - linked TROPONIN ECG Consider a CXR for other causes
What are the signs of angina on ECG / ETT
ST depression + T wave inversion during an attack - mild ischarmic changes
May show prior MI (Q waves) or LVH (ST depression)
How do you further investigate angina
CT / invasive angiography - show if CAD and decide whether medication, PCI or CABG
Non-invasive functioning imaging
What are non invasive functional imaging options
ETT = 1st line (resting + exercise ECG)
Symptoms + ECG changes when exercise
Myocardial perfusion imaging
Image on rest then drug to stress heart + image
Infarct if no image even at rest, ischaemia if no image on stress
Cardiac MRI
When is ETT harder to do
Pregnancy
High BP
Elderly
CI in aortic stenosis
What are general measures in stable angina
Stop smoking Control BP Control DM Lifestyle Treat anaemia, thyroid, tachycardia
What is prognostic / 2 prevention which everyone should receive unless CI
Aspirin 75mg daily
Statin 80mg
ACEI - stabilise
BB but likely already on
What is symptomatic treatment
GTN every 5 minutes causes vasodilatation
Repeat
If still pain after repeat dose = call an ambulance
What is prophylactic treatment
BB (reduce HR and demand)
CCB - relax coronary / contration / vasodilataion
What do you do if not controlled
Use rate limiting CCB if mono therapy but change to vasodilator if dual
Increase to dose
Dual therapy
Add on a third whilst waiting for surgery
What are 3rd line options
Nicorandil - vasodilator K activation
Ivabradine - reduce SA node rate
Long acting nitrate (isosorbide mononitrate)
What does Ivabradine do
Slows diastolic depolarisation reducing Hr and O2 demand
Only use if HR >70
Use if can’t tolerate BB
What must you exclude as a cause of angina
Aortic stenosis
What are surgical options
CABG
PCI
What are SE of GTN
Headache
Hypotension
Flushing
Tachycardia
What are SE of Ivabradine
Metabolised by p450
Visual
Brady
Headache
When is nicorandil CI and what are SE
LV failure / pulmonary oedema
Hypotension
Hypovolaemia
SE
Headache
Flushing
Anal ulceration
What can you develop with nitrates
Tolerance
Only seen in long acting
Reduce time between dose
What does PCI do
Dilate artery using balloon and insert stent
Do at angiography if extensive disease
Use femoral / radial / brachial
What must you continue after PCI
Dual anti-platelet 12 months
PCI or CABG
PCI higher risk of restenosis but lower adverse risks
When is CABG used
Left main stem
Triple vessel including LAD
Abnormal LV
Benefits of CBAG
Lasts longer
Less revasculisation
Open heart surgery
Saphenous vein used to bypass
When is surgery indicated
Angina unresponsive to medical Rx
Unstable angina
Unsuccessful PCI
When do you refer to cardiology
Routine if stable
Urgent if unstable
What do you look for in examination
Sternotomy suggesting CABG or scar on inner calf where vein harvested
Scar in femoral or brachial for PCI
