Stable Ischaemic Heart Disease

Question 1

Define Stable Angina

Answer 1

Pain/pressure in the chest due to myocardial ischaemia without necrosis (possibly with radiation) but not at rest.

Question 2

Name 6 causes of Stable Angina

Answer 2

Obstructive Coronary Atheroma
Coronary Artery Spasm
Coronary Artery Inflammation
Anaemia
LVH
Thyrotoxicosis

Question 3

What are the risk factors for SIHD?

Answer 3

Old - Certain Races - Male - FH - Smoker - Low exercise - Poor Diet - Diabetes - Hypertension - Hypercholesterolaemia

Question 4

Describe the site, character and radiation of Ischaemic heart pain?

Answer 4

Retrosternal (Centre)
Tight band/pressure or heaviness
Radiates to neck, jaw and medial arms

Question 5

What triggers and relieves symptoms of SIHD?

Answer 5

Triggered by Stress, exertion, cold weather and large meals

Relieved by rest & GTN spray

Question 6

What could you see on an examination of a SIHD patient?

Answer 6

Tar Staining - smoker
Obesity
Xanhalasma/Corneal Arcus - Hypercholesterolaemia
Hypertension
Retinopathy - Diabetes or Hypertension
Reduced peripheral pulses + abdominal bruit - AAA
Pallor- Anaemia
Elevated JVP, basal crackles & peripheral oedema - Heart Failure
Pansystolic murmur at mitral - Mitral Regurgitation
Ejection systolic murmur at Aortic - Aortic Stenosis
Hyperreflexia if thyrotoxicosis
Tachycardia

Question 7

How would you investigate suspected SIHD?

Answer 7

Bloods - FBC, lipid profile, Glc, U&Es , LFTs & thyroid function
CXR
ECG
Exercise Tolerance Test (ETT)
Myocardial Perfusion Imaging
Coronary Angiography

Question 8

What would an ECG show in a SIHD patient?

Answer 8

Pathological Q waves indicative of a past MI

High voltages, ST depression and/or Strain pattern indicates LVH

Question 9

Whats the use of an ETT in a SIHD patient?

Answer 9

Its needed to confirm the diagnosis

A +ve test shows ST depression and typical symptoms.

Question 10

What does coronary angiography do for SIHD patients?

Answer 10

Determines the size/location of an obstruction and what type of treatment is needed (meds vs revascularisation)
So its essential in any high risk patient

Question 11

How do we treat Stable Angina?

Answer 11

Firstly address risk factors to prevent worse future disease.
Meds to treat symptoms and limit disease progression
Revascularisation by PCI or CABG

Question 12

What meds treat the symptoms of angina?

Answer 12

B-blockers, CCBs, K openers (Reduces contractility and vasodilates - Nicorandil) & nitrates (Isosorbide Mononitrate)
And funny channel blocker Ivabradine which slows heart rate through increasing time to depolarisation to threshold in the pacemaker cell.

Question 13

What meds treat the disease behind stable angina?

Answer 13

Statins
ACEIs
Aspirin or Clopidogrel

Question 14

What type of PCI is used in coronary revascularization?

Answer 14

Percutaneous Transluminal Coronary Angioplasty

Question 15

What are the advantages of CABG over PCI?

Answer 15

CABG is better in multi vessel disease.

Unlike PCI it can help pronostically as well as the symptoms.

Question 16

In what unusual way can SIHD present?

Answer 16

Without pain but with SOBOE, Excessive Fatigue OE and Near Syncope OE.
USually in people with reduced pain sensation e.g. elderly & diabetics

Question 17

What is the classification of angina stages?

Answer 17

Canadian Cardiovascular Society scale of Angina Severity (CCS scale):
1 - Asymptomatic unless strenous acitvity
2 - Slight limitation e.g. walking >2 blocks or mu;tiple flights of stairs
3 - Marked Limitation e.g. i flight of stairs
4 - Cant really dress or wash etc