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Systems: Cardiovascualar AB > Stable Angina: Investigation, Diagnosis and Management > Flashcards

Stable Angina: Investigation, Diagnosis and Management 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 angina pectoris?

A

Cardiac chest pain

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3
Q

Why does myocardial ischaemia occur?

A

Mismatch between supply of O2 and metabolites to myocardium and the myocardial demand for them

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4
Q

What is the main cause of myocardial ischaemia?

A

Reduction in coronary blood flow to the myocardium

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5
Q

What can cause 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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6
Q

What uncommon causes of myocardial ischaemia are there?

A
  • Due to reduced O2 transport

- Due to pathologically increased myocardial O2 demand

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7
Q

What condition can cause reduced O2 transport?

A

Anaemia of any cause

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8
Q

What conditions can cause an increase in myocardial O2 demand?

A
  • Left ventricular hypertrophy

- Thyrotoxicosis

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9
Q

What can cause left ventricular hypertrophy?

A 
-Significant
persistent hypertension
-Significant aortic stenosis
-Hypertrophic cardiomyopathy
-
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10
Q

What is the most common cause of angina?

A

Coronary atheroma

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11
Q

How do the symptoms of angina occur?

A

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

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12
Q

Give examples of situations in which myocardial oxygen demand increases.

A

When HR and BP rise:

  • Exercise
  • Anxiety/emotional stress
  • After a large meal
  • Cold weather
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13
Q

What is the typical distribution of pain and discomfort in angina?

A

Across left chest and down medial side of left arm

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14
Q

What must happen to coronary arteries before symptoms of angina are experienced?

A

Obstructive plaque that covers >70%

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15
Q

What will spontaneous plaque rupture and local thrombosis with degrees of occlusion result in?

A

Acute coronary syndromes

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16
Q

What symptoms will there be will a fatty streak in coronary arteries?

A

No symptoms

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17
Q

What symptoms will there be with a non-obstructive plaque in the coronary arteries?

A

No symptoms

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18
Q

Why is history essential to making a diagnosis of angina?

A

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

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19
Q

How is angina pain described?

  • Site
  • Character
  • Radiation
  • Aggravating and relieving factors
A
  • Site: retrosternal (watch for patients gestures)
  • Character: often tight band/pressure/heaviness
  • Radiation: neck and/or into jaw, down arms
  • Aggravating factors: exertion and emotional stress
  • Relieving factors: physical rest, rapid improvement with GTN
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20
Q

What features make it unlikely to be angina?

A
  • 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
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21
Q

In the differential diagnosis, what are CV causes?

A
  • Aortic dissection

- Pericarditis

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22
Q

In the differential diagnosis, what are the respiratory causes?

A
  • Pneumonia
  • Pleurisy
  • Peripheral pulmonary emboli
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23
Q

In the differential diagnosis what are the musculoskeletal causes?

A
  • Cervical disease
  • Costochondritis
  • Muscle spasm or strain
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24
Q

In the differential diagnosis, what are the GI causes?

A
  • Gastro-oesophageal reflux
  • Oesophageal spasm
  • Peptic ulceration
  • Biliary colic
  • Cholecystitis
  • Pancreatitis
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25
Q

In the very rare occasion that myocardial ischaemia occurs with no chest pain, what other symptom may it present with on exertion?

A
  • Breathlessness on exertion
  • Excessive fatigue on exertion for activity undertaken
  • Near syncope on exertion
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26
Q

Who is more likely to have symptoms other than chest pain n myocardial ischaemia?

A

-Elderly
-Those with diabetes mellitus
Probably dues to reduced pain sensation

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27
Q

What are the degrees of severity according to the Canadian classification of angina severity CCS?

A

I Ordinary physical activity does not cause angina, symptoms only on significant exertion
II Slight limitation of ordinary activity, symptoms on walking 2 blocks or >1 flight of stairs
III Marked limitation, symptoms o walking 1-2 blocks or 1 flight of stairs
IV Symptoms on any activity, getting washes/dressed causes symptoms

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28
Q

What non-modifiable risk factors are there?

A
  • Age
  • Gender
  • Creed
  • Family history
  • Genetic factors
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29
Q

What modifiable risk factors are there?

A
  • Smoking
  • Lifestyle
  • Diabetes mellitus
  • Hypertension
  • Hyperlipidaemia
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30
Q

What signs might be found on examination?

A
  • Tar stains on fingers
  • Obesity
  • Xanthalasma and corneal arcus
  • Hypertension
  • Abdominal aortic aneurysm arterial brutis, absent or reduced peripheral pulses
  • Diabetic retinopathy, hypersensitive retinopathy on fundoscopy
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31
Q

What are signs of exacerbating or associated conditions?

A
  • Pallor of anaemia
  • Tachycardia, tremor, hyper-flexia 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
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32
Q

What investigations should be carried out?

A
  • Bloods
  • CXR
  • ECG
  • Exercise tolerance test
  • Myocardial perfusion imaging
  • CT coronary angiography
  • Invasive angiography
  • Cardiac catheterisation/ coronary angiography
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33
Q

What bloods should be done?

A
  • FBC
  • Lipid profile
  • Fasting glucose
  • Electrolytes
  • Liver and thyroid tests
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34
Q

Why is a CXR carried out?

A

Often helps show other causes of chest pain and can help show pulmonary oedema

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35
Q

What is the result of most ECGs in the investigation of angina?

A

Normal in >50% of cases

36
Q

What may be seen on an ECG in the investigation of angina?

A
  • Prior myocardial infarction (pathological Q-waves)

- Left ventricular hypertrophy (high voltages, lateral ST-segment depression or strain pattern)

37
Q

Which investigation can often confirm the diagnosis of angina?

38
Q

What does the ETT rely on?

A

Ability to walk for long enough to produce sufficient CV stress

39
Q

What indicates a positive ETT result?

A

Typical symptoms and ST segment depression

40
Q

What does a negative ETT result mean?

A
  • Doesn’t exclude significant coronary atheroma

- If negative at high workload, overall prognosis is good

41
Q

In what ways s myocardial perfusion imaging superior to ETT?

A
  • Detection of CAD
  • Localisation of ischaemia
  • Assessing size of area affected
42
Q

What are disadvantages of myocardial perfusion imaging?

A
  • Expensive
  • Involves radiotherapy
  • Depends on availability
43
Q

What type of stress is used in myocardial perfusion imaging?

A
  • Exercise

- Pharmacological stress

44
Q

Give examples of pharmacological stress used in myocardial perfusion imaging? (3)

A
  • Adenosine
  • Dipyridamole
  • Dobutamine
45
Q

How is myocardial perfusion imaging carried out?

A
  • Radionuclide tracer is injected at peak stress on one occasion, images obtained and at rest on another
  • Comparison between stress and rest images
  • Normal myocardium takes up tracer
46
Q

How is ischaemia indicated in myocardial perfusion imaging?

A

Tracer seen at rest but not after stress

47
Q

How is infarction indicated in myocardial perfusion imaging?

A

Tracer seen neither at rest or after stress

48
Q

When is invasive angiography indicated?

A
  • Early or strongly positive ETT
  • Angina refractory to medical therapy
  • Diagnosis not clear after non-invasive tests
  • Young cardiac patients due to work/life effects
  • Occupation or lifestyle with risk
49
Q

What aids in the decision over which treatment options are possible?

A

Definition of coronary anatomy with sites, distribution and nature of atheromatus disease by cardiac catheterisation/ coronary angiography

50
Q

What are the treatment options available?

A
  • Medication

- Percutaneous coronary interventions (angioplasty and stenting or CABG surgery)

51
Q

How is cardiac catheterisation/coronary angiography carried out?

A
  • Almost always done under local anaesthetic
  • Arterial cannula inserted into femoral or radial artery
  • Coronary catheters passed to aortic root and introduced into the ostium of coronary arteries
  • Radio-opaque contrast injected down coronary arteries and visualised on X-ray
52
Q

Why are vies of the coronary arteries take in different planes?

A

Atheroma often eccentric in nature

53
Q

Why is invasive coronary angiography a 2-D lumenogram?

A

Iodinated contrast or dye is passed through the arteries

54
Q

What general measures are considered in treatment strategies?

A

Address risk factors

  • BP
  • DM
  • Cholesterol
  • Lifestyle
55
Q

What medical treatment is considered in treatment strategies?

A

-Drugs to reduce disease progression and symptoms

56
Q

When would revascularisation be considered as a treatment option?

A

If symptoms are not controlled

57
Q

What revascularisation options are there?

A
  • Percutaneous coronary intervention

- Coronary artery bypass grafting

58
Q

What drugs are available to influence disease progression?

A
  • Statins
  • ACE inhibitors
  • Aspirin
59
Q

When should statins be considered?

A

If total cholesterol >3.5mmol/L

60
Q

What do statins do?

A

Reduce LDL cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS

61
Q

When should ACE inhibitors be considered?

A

If increased CV risk and atheroma

62
Q

What do ACE inhibitors do?

A

Stabilise endothelium and also reduce plaque rupture

63
Q

What dosage of aspirin should be given?

64
Q

What is the substitute for aspirin if someone is intolerant?

A

Clopidogrel

65
Q

What does aspirin do?

A

May not directly affect plaque but does protect endothelium and reduces platelet activation/aggregation

66
Q

What drugs can be used for the relief of symptoms?

A
  • B-blockers
  • Ca channel blockers
  • Ik channel blockers
  • Nitrates
  • K channel blockers
67
Q

What is the aim of drugs used for the relief of symptoms?

A

Achieve resting heart rate <60bpm

68
Q

What do B-blockers for?

A

Reduces myocardial work and have anti-arrhythmic effects

69
Q

Give examples of central acting Ca channel blockers. (2)

A
  • Diltiazem

- Verapamil

70
Q

What is Ivabridine (Ik channel blocker)?

A

A new medication which reduces sinus node rate

71
Q

Give examples of peripheral acting Ca channel blockers.

A
  • Amlodipine

- Felodipine

72
Q

What do Ca channel blockers do?

A

Produce vasodilatation

73
Q

What do nitrates do?

A

Produce vasodilation

74
Q

How are nitrates used?

A

Used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray for immediate use

75
Q

What is an example of a K channel blocker?

A

Nicorandil

76
Q

What are helpful in pre-conditioning

A

Nitrate molecule and K channel

77
Q

What procedures are classed as percutaneous coronary intervention?

A
  • Percutaneous transluminal coronary angioplasty

- Stenting

78
Q

How is PCI carried out?

A

-Similar beginnings to coronary angiography but cross stenotic lesion with guide wire and squash atheromatous plaque into walls with balloon and stent.

79
Q

Why are aspirin and clopidogrel used together after somone has had a stent fitted

A

Taken whilst endothelium covers the stent struts and it is no longer seen as a foreign body with associated risk of thrombosis

80
Q

PCI is effective at managing symptoms but what are the disadvantages?

A
  • No evidence it improves prognosis in stable disease
  • Small risk of procedural complications
  • Risk of restenosis
  • Still need to continue disease modifying medication
81
Q

What is the best form of CABG for stable angina?

A

Multi-vessel CABG

82
Q

In what subgroups might CABG confer prognostic benefit?

A
  • Those with >70% stenosis of left main stem artery
  • Significant proximal 3 vessel coronary artery disease
  • 2 vessel coronary artery disease that includes significant stenosis of proximal left anterior descending coronary artery and who have an ejection fraction <50%
83
Q

How do the up front risk of CABG compare to PCI?

A

Significantly increased

84
Q

What are the lasting benefits of CABG?

A

80% symptom free 5 years later

85
Q

What is the predictable deterioration in vein grafts?

Systems: Cardiovascualar AB (42 decks)

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