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Cardiovascular - exam style qs > Stable ischaemic heart disease and angina > Flashcards

Stable ischaemic heart disease and angina Flashcards

1
Q

Definition

A

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

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2
Q

Pathophysiology

A

Mismatch between supply of oxygen and metabolites to myocardium and myocardial demand

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3
Q

Commonest cause of reduced blood flow through coronary arteries

A

Obstructive coronary atheroma

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4
Q

2 key characteristics of stable angina

A

Typical distribution of pain (centre of chest, left neck and jaw)
Precipitated by excess myocardial oxygen demand eg on exertion

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5
Q

What stage of atherosclerosis causes stable angina

A

Obstructive plaque

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6
Q

Characteristics of stable angina pain

A

Site - retrosternal
Character - often tight band/pressure/heaviness
Radiation - neck, jaw, down arms
Aggravating - with exertion, emotional stress and relieving factors - rapid improvement with GTN or physical rest

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7
Q

Describe the classification system for stable angina

A

Canadian classification of angina severity
I - symptoms on significant exertion
II - symptoms after 2 blocks or more than 1 flight of stairs
III - symptoms on 1 flight of stairs
IV - symptoms on any activity

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8
Q

Non-modifiable risk factors

A 
age
gender
creed
family history
genetics
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9
Q

Modifiable risk factors

A 
smoking
lifestyle - exercise and diet
diabetes mellitus
hypertension
hyperlipidaemia
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10
Q

Signs

A

tar staining
obesity
Xanthalasma and corneal arcus
hypertension
abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses
diabetic retinopathy, hypertensive retinopathy on fundoscopy

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11
Q

Signs of exacerbating or associated conditions

A

pallor of anaemia
tachycardia, tremo, hyper-reflexia of hyperthyroidism
ejection systolic murmur of mitral regurgitation
signs of heart failure such as basal crackles, elevated JVP, peripheral oedema

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12
Q

Investigations

A 
Bloods 
CXR
ECG
Exercise tolerance test
Myocardial perfusion imaging
CT coronary angiography
Invasive angiography
Cardiac catherterisation
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13
Q

Three steps in treatment strategies

A

Address general measures
Medical treatment
Revascularisation

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14
Q

What comes under general measures in terms of treatment of angina

A

Address risk factors: BP, diabetes mellitus, cholesterol, lifestyle

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15
Q

What medical treatment influences the disease progression of stable angina

A

Statins - reduces LDL cholesterol deposition and reduces plaque rupture risk
ACE inhibitors - lowers BP so stabalises endothelium
Aspirin - Protects endothelium and reduces platelet aggregation

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16
Q

What medical treatment relieves symptoms

A 
Beta blockers - reduces myocardial work
Calcium channel blockers
Ik channel blockers
Nitrates - vasodilation, GTN spray
K channel blockers
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17
Q

What two methods are options if medical treatment isn’t enough

A

Percutaneous coronary intervention (PCI)

Coronary artery bypass surgery (CABG)

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18
Q

What three things do drugs reduce in order to reduce cardiac workload

A

heart rate
myocardial contractility
afterload

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19
Q

What three types of drugs reduce the heart rate

A

Beta-adrenoceptor antagonists
Ivabradine
Calcium channel blockers

20
Q

What two types of drugs are vasodilators

A

Calcium channel blockers

Nitrates (oral and sublingual)

21
Q

What is the purpose of drug treatment (5 things)

A 
Relieve symptoms
Halt disease process
Regression of the disease process
Prevent myocardial infarction
Prevent death
22
Q

Which layer in the artery wall do most changes occur in atherosclerosis

A

tunica intima

23
Q

Name 2 examples of beta blockers

A

Bisoprolol

Atenolol

24
Q

How do beta blockers work

A

They block beta 1 and beta 2 receptors, blocking the response to adrenaline and noradrenaline ie the sympathetic system

25
Q

What three things do beta blockers decrease to decrease myocardial oxygen demand

A

Heart rate
Contractility
Systolic wall tension

26
Q

What is the rebound phenomena in terms of beta blockers?

A

DO NOT STOP BETA BLOCKERS SUDDENLY

sudden cessation may cause a myocardial infarction

27
Q

When do you not use beta blockers?

A

Asthma
Peripheral vascular disease
Heart failure
Bradycardia

28
Q

Adverse drug reactions

A 
Tiredness/fatigue
Lethargy
Impotence
Bradycardia
Bronchospasm
29
Q

Name 2 examples of rate limiting calcium channel blockers

A

Diltiazem

Verapamil

30
Q

Name an example of a vasodilating calcium channel blocker

A

Amlodipine

31
Q

How do vasodilators aid in reducing myocardial workload

A

They reduce vascular tone so produce vasodilation, which decreases the afterload

32
Q

Adverse drug reactions to calcium channel blockers

A

Ankle oedema
Headache
Flushing
Palpitation

33
Q

How do nitrates work

A

Arteriolar dilatation - reduced cardiac afterload
Peripheral venodilatation - reduced venous return - reduced cardiac preload
Relieves coronary vasospasm
Redistributes myocardial blood flow to ischaemic areas of the myocardium

34
Q

What are the three forms of nitrates and when would each be used

A

GTN - rapid treatment, sublingual route
Oral nitrates - sustained release, used for prophylaxis
IV nitrates - unstable angina, in combination with heparin

35
Q

Example of GTN sublingual drug

A

Glyceryl trinitrate

36
Q

Example of oral nitrate

A

Isosorbide mononitrate

Isosorbide dinitrate

37
Q

Adverse drug reactions to nitrates

A

Headache

Hypotension - GTN syncope

38
Q

What is GTN syncope

A

When patient gets acute and rapid reduction in cardio return and faints

39
Q

One example of potassium channel opener

A

Nicorandil

40
Q

Effect of potassium channel opener, Nicorandil

A

Entry of potassium into cardiac myocytes inhibits calcium influx so negative inotropic effect

41
Q

What does Ivabradine do

A

Selective sinus node inhibitor, reduces heart rate

42
Q

Examples of antiplatelet agents

A

low dose ASPIRIN
Clopidogrel
Ticagrelor

43
Q

When should aspirin be used in the case of angina

A

In adults unable to tolerate beta-blockers
or
In combination with beta-blockers in patients inadequately controlled

44
Q

Why should you be careful when prescribing aspirin, especially to the elderly

A

common cause of GI bleed

45
Q

What are statins

A

Cholesterol lowering agents

46
Q

Name an example of a statin

A

Simvastatin
Pravastatin
Atorvastatin

47
Q

Recap of treatment regimen for stable angina

A 
Beta blocker
Aspirin
Statin
CCB
Nitrate
Nicorandil
Refer to cardiology work up for possible stenting

Cardiovascular - exam style qs (20 decks)

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