Stable angina Flashcards by Anna Coull

define angina

a discomfort/pain in the chest and/or adjacent areas associated with myocardial ischaemia (lack of O2 to the heart) but without myocardial necrosis

How well did you know this?

Not at all

Perfectly

describe the pathophysiology of myocardial ischaemia and resultant anginal symptoms

the supply of O2 and metabolites to myocardium (muscular tissue of the heart) doesn’t meet/match the myocardial demand for them

How well did you know this?

Not at all

Perfectly

what is the most common cause of angina?

obstructive coronary atheroma (fatty deposits/plaque building up in arterial walls)

How well did you know this?

Not at all

Perfectly

what is an uncommon cause of reduced coronary blood flow to the myocardium?

coronary artery spasm - sudden tightening of the muscles within the arteries of your heart.

When this occurs, your arteries narrow and prevent blood from flowing to your heart

How well did you know this?

Not at all

Perfectly

what is a very rare cause of reduced coronary blood flow to the myocardium?

coronary inflammation/arteritis (inflammation of arterial walls as a result of infection or autoimmune response)

How well did you know this?

Not at all

Perfectly

In what situations does myocardial oxygen demand increase?

when HR and BP rise so during exercise, anxiety/emotional stress, cold weather or after a large meal

How well did you know this?

Not at all

Perfectly

what happens when there is an increased demand for O2 by the heart but there is obstructed coronary blood flow?

myocardial ischaemia occurs and then the symptoms of angina

How well did you know this?

Not at all

Perfectly

at what point does an obstructive plaque cause stable angina?

if it obstructs >70% of the lumen

How well did you know this?

Not at all

Perfectly

acute coronary syndromes occur when what has happened with the lumen of a vessel?

spontaneous plaque rupture and local thrombosis, with degrees of occlusion

How well did you know this?

Not at all

Perfectly

why is taking a history important in the diagnosis of stable angina

Essential to establish the characteristics of patients pain and to differentiate it from other causes of chest pain:

How well did you know this?

Not at all

Perfectly

What things can you find about patient’s chest pain from taking a history? (5)

Site of pain - retrosternal (retro- behind)

Character of pain: often tight band/pressure/heaviness.

Radiation sites: neck and/or into jaw, down arms.

Aggravating e.g. with exertion, emotional stress

& relieving factors e.g. rapid improvement with GTN or physical rest.

How well did you know this?

Not at all

Perfectly

what features make the diagnosis less likely to be angina? (7)

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.

Comes on consistently at rest

How well did you know this?

Not at all

Perfectly

what other cardiovascular causes could there be for chest pain that aren’t angina?

aortic dissection - tear in the aorta

pericarditis

How well did you know this?

Not at all

Perfectly

what respiratory causes could there be for chest pain? (3)

pneumonia
pleurisy
peripheral pulmonary emboli (pleuritic)

How well did you know this?

Not at all

Perfectly

what musculoskeletal causes could there be for chest pain? (3)

cervical disease

costochondritis (inflammation of cartilage attaching ribs to sternum)

muscle spasm or strain

How well did you know this?

Not at all

Perfectly

what GI causes could there be for chest pain? (3)

Gastro-oesophageal reflux
oesophageal spasm 
peptic ulceration
biliary coli
cholecystitis 
pancreatitis

How well did you know this?

Not at all

Perfectly

when myocardial ischaemia occurs with no chest pain what other symptoms should you look for on exertion?

breathlessness
excessive fatigue for activity undertaken
near syncope

How well did you know this?

Not at all

Perfectly

who is most likely to present with myocardial ischaemia without chest pain?

the elderly or those with diabetes probably due to reduced pain sensation

How well did you know this?

Not at all

Perfectly

risk factors of stable angina? (10)

smoking
hypertension
hyperlipidaemia 
age
diabetes
gender - male> female
family history
genetic factors
exercise
diet

How well did you know this?

Not at all

Perfectly

How does stable Angina almost always come on?

stable angina almost always comes on exertion ie walking up a hill NOT lying down or walking around the supermarket

How well did you know this?

Not at all

Perfectly

if chest pain comes on at rest constantly then what is it not likely to be

angina

stable angina is more common in people with what?

high cardiovascular risk

what is treatment for Angina based on?

symptoms

Describe the nature of pain experienced by a person with angina?

heaviness in the front of chest
chest tightness or pressure
pain can radiate down the arms, up the neck or into their jaw
can be exacerbating - get worse in cold weather, after a meal, due to emotional stress or exercise

Glyceryl trinitrate (GTN) treatment

can improve a number of chest problems however if your symptoms improve consistently with GTN this can further prove diagnosis of stable Angina

general definition of ischaemia?

supply and demand mismatch - reduced blood flow

what is stable angina almost always caused by?

arterial stenosis - narrowing of the coronary arteries

What can an exercise test be used for?

to reproduce symptoms and demonstrate ischaemia

Problems with exercise treadmill test?

most people with stable angina are elderly so they may not have the capacity to actually exercise to produce sufficient CV stress - could do bike test instead however as this is non weight baring it's not very sensitive or specific high false positive rate

Why might someone have trouble exercising?

osteoarthritis | peripheral vascular disease

Describe test done to demonstrate myocardial ischaemia?

stress MRI scan or stress myocardial perfusion test

what is the ischaemic cascade?

series of biochemical reactions that are initiated in the brain and other aerobic tissues after seconds to minutes of ischemia (inadequate blood supply). This is typically secondary to stroke, injury, or cardiac arrest due to heart attack. ``` e.g occlusion Myocardial O2 consumption increases O2 demand exceeds supply ATP production decreases, lactic acid increases contractility diminishes over time abnormal wall motions ECG changes - ST segment Angina ```

what investigations can be done for stable angina?

blood- full blood count, lipid profile and fasting glucose CXR ECG - normal result in >50% of cases

Pros and cons of myocardial perfusion imaging

PROS:- better than exercise test in detection of Coronary Artery disease CRD - Can localise ischaemia and assess size of area affected CONS:- expensive, involves radioactivity

difference between stable and unstable angina?

If the pain happens during certain activities and goes away with rest, it's called stable angina. However, if the chest pain becomes more severe or frequent, lasts longer, or occurs while resting it's called unstable angina.

what happens during myocardial perfusion imaging?

Radionuclide tracer injected (iv) at peak stress on one occasion, images obtained; and at rest on another. Comparison between stress and rest images. Normal myocardium takes up tracer as blood is flowing through it - ischaemic part wouldn't as no blood flow

what does it mean if you see the tracer at rest but not after stress?

ischaemia

what does it mean if you can't see the tracer at rest or after stress?

infarction

how is CT coronary angiography invasive

invasive due to radiodye injected into arteries

what is CT coronary angiography used for?

Definition of coronary anatomy with sites, distribution and nature of atheromatous disease enables decision over what treatment options are possible.

Medical treatment for stable angina: Statins

Reduce LDL-cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS. don't make CHD go backwards or arrest the disease but just cause slow progression and reduce stress modify the disease

Medical treatment for stable angina: ace inhibitors

not commonly used | but used if increased CV risk and atheroma to stabilise endothelium and reduce plaque rupture

Medical treatment for stable angina: aspirin

aspirin is primary preventative | reduce chance of primary spontaneous event - may have upset GI though

what do you do if a patient is still symptomatic despite treatment?

Angioplasty a minimally invasive, endovascular procedure to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.

what is a bypass used for

redirects artery/veins within the heart to coronary arteries or aorta to maintain atrial bloodflow to atrial myocardium

Medical treatment for stable angina: beta blockers

for supply and demand issues | reduced myocardial work and have anti-arrhythmic effects

Coronary artery bypass graft surgery CABG

to restore normal blood flow to an obstructed coronary artery CABG often best option for stable angina more risky than PCI - Angioplasty 80% symptom free 5 years later

Percutaneous coronary intervention/ angioplasty << same thing

non-surgical procedure that uses a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis.

signs of stable angina (8)

``` GTN relief tar staining xanthalasma/corneal arcus high blood pressure tachycardia murmurs HF signs AAA - abdominal aortic aneurysm ```

symptoms of stable angina? (5)

constricting discomfort in front of chest, arms, neck and jaw brought on by exertion in stable angina - after meals, cold air or exercise SOB Syncope excess fatigue

diagnosis / investigation of stable angina (7)

``` ECG - exclude ACS acute coronary syndrome Cardiac catheterisation CT angiography stress echo/ MRI / ETT bloods CXR myocardial perfusion imaging ```