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Stable Angina Flashcards

1
Q

What is angina?

A

A discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis

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2
Q

What is a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis called?

A

Angina

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3
Q

What is myocardial ischaemia?

A

Lack of oxygen to the heart

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4
Q

What is a lack of oxygen to the heart called?

A

Myocardial ischaemia

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5
Q

What is ischaemia?

A

Restriction in blood supply to tissues causing a shortage of oxygen

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6
Q

What is restriction in blood supply to tissues causing a shortage of oxygen called?

A

Ischaemia

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7
Q

What is the pathophysiology of myocardial ischaemia and resultant angina symptoms?

A

Mismatch between supply of oxygen and metabolites to myocardium and the myocardial demand for them

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8
Q

What is the mismatch between nutrients delivered to the myocardium and the demand for them due to?

A

Most commonly due to a reduction in coronary blood flow to the myocardium

Uncommonly due to reduced oxygen transport

Uncommonly due to pathologically increased myocardial demand

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9
Q

What can casue a reduction in coronary blood flow to the myocardium?

A

Obstructive coronary atheroma (very common)

Coronary artery spasm (uncommon)

Coronary inflammation/arteritis (very rare)

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10
Q

What causes reduced oxygen transport?

A

Anaemia

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11
Q

What leads to pathologically increased myocardial oxygen demand?

A

Left ventricular hypertrophy (LVH) as seen in significant hypertension, aortic stenosis and hypertrophic cardiomyopathy

Thyrotoxicosis

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12
Q

What does LVH stand for?

A

Left ventricular hypertrophy

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13
Q

What is hypertrophic cardiomyopathy?

A

Portion of the heart becomes thickened without a known cause

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14
Q

What is it called when a portion of the heart becomes thickened without a known cause?

A

Hypertrophic cardiomyopathy

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15
Q

What is thyrotoxicosis?

A

Excess of thyroid hormone in the body

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16
Q

What is excess of thyroid hormone in the body called?

A

Thyrotoxicosis

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17
Q

What is the most common cause of angina?

A

Coronary atheroma

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18
Q

Why does coronary atheroma cause angina?

A

On activity with the increased myocardial oxygen demand obstructed coronary blood flow leads to muocardial ischaemia and tehn the symptoms of angina

Myocardial oxygen demand increases in situations where heart rate and blood pressure rise, such as exercise, anxiety/emotional stress and after a large meal

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19
Q

When does myocardial oxygen demand increase?

A

In situations where heart rate and blood pressure rise, such as exercise, anxiety/emotional stress and after a large meal

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20
Q

What is arteritis?

A

Inflammation of the walls of the arteries

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21
Q

What is inflammation of the walls of the arteries called?

A

Arteritis

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22
Q

What is the typical distribution of pain due to angina?

A

Along the chest to the left arm

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23
Q

How would you describe the process of atherosclerosis?

A

Progressive process

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24
Q

When does atherosclerosis go from no symptoms to stable angina to acute coronary syndromes?

A
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25
Where does a lot of the diagnosis for angina come from?
The history
26
What is it essential to establish about the pain from angina?
The character of the pain to differentiate it from other causes of chest pain
27
What kind of things are needed to be known about angina pain?
Site of pain Character of pain Radiation sites Aggravating Relieving factors
28
What is the site of pain?
Retrosternal
29
What is the character of the pain?
Often tight band/pressure/heaviness
30
What are the radiation sites of the pain?
Neck and/or into jaw, down arms
31
What aggravates the pain?
Exertion and emotional stress
32
What are relieving factors for the pain?
Rapid improvement with GTN or physical rest
33
When can myocardial ischaemia occur without chest pain?
In the elderly or with diabetes mellitus due to reduced pain sensation
34
What other symptoms are present when pain is not for myocardial ischaemia?
Breathlessness on exertion Excessive fatigue on exertion for activity undertaken Near syncope on exertion
35
What are examples of features that make angina less likely?
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 Begins sometimes after exercise Lasting for hours
36
What is required to differentiate angina from other possible causes for the pain?
Differential diagnosis
37
What are other systems that cause similar pain to angina?
Cardiovascular Respiratory Musculoskeletal GI
38
What are some cardiovascular causes that are similar to angina but the pain has different characteristics?
Aortic dissection Pericarditis
39
What are some respiratory causes that are similar to angina but the pain has different characteristics?
Pneumonia Pleurisy Peripheral pulmonary emboli
40
What are some musculoskeletal causes that are similar to angina but the pain has different characteristics?
Cervical disease Costochondritis Muscle spasm Strain
41
What are some GI causes that are similar to angina but the pain has different characteristics?
Gastro-oesophageal reflux Oesophageal spasms Peptic ulceration Biliart colic Cholecystitis Pancreatitis
42
What is retrosternal?
Behind the breastbone (sternum)
43
What are the classes of angina severity?
I II III IV
44
What is the first class of angina severity?
Ordinary physical activity does not cause angina, symptoms only significant on exertion
45
What is the second class of angina severity?
Slight limitations of ordinary activity, symptoms on walking 2 blocks or more than 1 flight of stairs
46
What is the third class of angina severity?
Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs
47
What is the fourth class of angina severity?
Symptoms on any activity, getting washed/dressed causing symptoms
48
What are some risk factors for coronary artery disease?
Non-modifiable Age Gender Creed Family history and genetic factors Modifiable Smoking Lifestyle (exercise and diet) Diabetes mellitus Hypertension Hyperlipidaemia
49
What are some things seen in the examination for angina?
Tar stains on fingers Obesity Xanthalasma and corneal arcus (hypercholesterolaemia) Hypertension
50
What are some signs during the examination of exacerbating or associated conditions?
Pallor of anaemia Tachycardia, tremor, hyper-reflexia of hyperthyroidism Ejection systolic murmur, plateau pulse of aortic stenosis Pansystolic murmur of mitral regurgitation Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema
51
What investigations are done to diagnose angina?
Bloods Chest X-ray Electrocardiogram Exercise tolerance test (ETT) Myocardial perfusion imaging CT coronary angiography Cardiac catheterisation/coronary angiography (invasive)
52
What bloods are done to diagnose angina?
Full blood count Lipid profile and fasting glucose Electrolytes Liver and thyroid tests
53
Why are chest X-rays useful for diagnosing angina?
Often helps to show other causes of chest pain and can help show pulmonary oedema
54
What can an electrocardiogram show?
Evidence of prior myocardial infarction or left ventricular hypertrophy
55
What is seen on an electrocardiogram for a previous myocardial infarction?
Pathological Q waves
56
What is seen on an electrocardiogram for left ventricular hypertrophy?
High voltages Lateral ST-segment depression
57
What does ETT stand for?
Exercise tolerance test
58
What is a problem with an exercise tolerance test?
Relies on ability to walk long enough to produce sufficient CV stress
59
What can you say about an exercise tolerance test coming back negative and angina?
Doesn't exclude significant amounts of atheroma but if negative at a high workload overall prognosis is good
60
What is seen in an exercise tolerance test when angina is positive?
Typical symptoms and ST-segment depression
61
What does myocardial perfusion imaging allow?
Localisation of ischaemia and assessing size of area affected
62
What are disadvantages of myocardial perfusion imaging?
Expensive Uses radioactivity Depends on availability
63
What is an invasive investigation for angina?
Cardiac catheterisation/coronary angiography
64
What does cardiac catheterisation/coronary angiography provide?
Definition of coronary anatomy with sites, distribution and nature of atheromatous disease Can decide whether medication alone or percutaneous coronary intervention (PCI) is needed
65
What does PCI stand for?
Percutaneous coronary intervention
66
What are the most common kinds of percutaneous coronary intervention (PCI)?
Angioplasty and stenting or coronary artery bypass graft (CABG) surgery
67
What does CABG stand up for?
Coronary artery bypass graft
68
What is the process of myocardial perfusion imaging?
1) Radionuclide tracer injected (IV) at peak stress and images obtained 2) Images obtained at rest 3) Comparison between stress and rest images 4) Normal myocardium takes up tracer (tracer seen at rest but not after stress is ischaemia, tracer seen neither at rest or after stress is infarction)
69
What is the condition when in a myocardial perfusion imaging the tracer is seen at rest but not after stress?
Ischaemia
70
What is the condition when in a myocardial perfusion imaging the tracer is not seen at rest or after stress?
Infarction
71
When would an invasive angiography be used?
Early or strongly positive ETT Angina refractory to medical therapy Diagnosis not clear after non-invasive tests Yound cardiac patients due to work/life effects Occupation or lifestyle with risk (such as divers)
72
What is an angiography?
A type of X-ray used to look at blood vessels
73
What are treatment strategies for angina?
Addressing risk factors Drugs to reduced disease progression Drugs to reduce symptoms Revascularisation (if symptoms are not controlled)
74
What are examples of drugs used to reduced disease progression of angina?
Statins ACE inhibitors Aspirin
75
When should statins be considered for treatment of angina?
If total cholesterol \> 3.5mmol/L
76
How do statins help to reduce angina?
Reduced LDL-cholesterol deposition in atheroma and also stabilises atheroma reducing plaque rupture and acute coronary syndrome
77
When should ACE inhibitors be used to prevent disease progression of angina?
Increased CV risk and atheroma
78
How do ACE inhibitors help to prevent disease progression of angina?
Stabilise endothelium and also reduce plaque rupture
79
How does the aspirin prevent disease progression of angina?
May not directly affect plaque but does protect endothelium and reduces platelet activation/aggregation
80
What are drugs used to reduce disease symptoms of angina?
Beta blockers Ca2+ channel blockers Ik channel blockers Nitrates K+ channel blockers
81
Why are beta blockers used to reduce symptoms of angina?
Reduces myocardial work and achieves resting heart rate \< 60bpm
82
How do CCB reduce symptoms of angina?
Centrally acting to achieve resting heart rate \< 60bpm Peripherally acting produces vasodilation
83
What is an example of a CCB used to treat symptoms of angina?
Diltiazem/verapamil for central Amlodipine and felodipine for peripheral
84
How do Ik channel blockers reduces symptoms of angina?
Reduces sinus node rated to achieve resting heart rate \< 60bpm
85
What is an example of a Ik channel blocker to treat symptoms of angina?
Ivabridine
86
How do nitrates help reduce symptoms of angina?
Produce vasodilation
87
How are nitrates used?
Short or prolonged acting tablets, patches or as rapidly acting sublinguinal GTN spray for immediate use
88
What is an example of a potassium channel blocker used to reduce the symptoms of angina?
Nicorandil
89
90
What are methods for revascularisation?
Percutaneous coronary intervention (PCI) Coronary artery bypass grafting (CABG)
91
How is percutaneous coronary intervention (PCI) done for revascularisation?
If stent is used aspirin and clopidogrel are taken whilst endothelium covers the stent and it is no longer seen as a foreign body with risk of thrombosis
92
What are disadvantages of percutaneous coronary intervention (PCI)?
No evidence improves prognosis in stable death (only good to reduce symptoms) Small risk of procedural complications (such as death or myocardial infarction) Risk of restenosis (reoccurence of narrowing artery)
93
Does percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have greater risks?
Coronary artery bypass grafting (CABG)
94
What are advantages of coronary artery bypass grafting (CABG)?
Good long lasting benefits, 80% symptoms free 5 years later
95
What is percutaneous coronary intervention (PCI)?
Non-invasive procedure that uses a catheter to place a stent to open up blood vessels
96
What is a non-invasive procedure that uses a catheter to place a stent to open up blood vessels?
Percutaneous coronary intervention (PCI)
97
What is coronary artery bypass grafting (CABG)?
Surgical procedure used to treat coronary heaert disease by diverting blood around narrowed parts of major arteries to improve blood flow to the heart
98
What is a surgical procedure used to treat coronary heaert disease by diverting blood around narrowed parts of major arteries to improve blood flow to the heart?
Coronary artery bypass grafting (CABG)

Cardiovascular LK (41 decks)

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