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R-Cradio-illness > Stable Ischaemic Heart Disease and Angina Presentation and Investigation > Flashcards

Stable Ischaemic Heart Disease and Angina Presentation and Investigation Flashcards

1
Q

What is angina?

A

Discomfort/pain in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis

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2
Q

What is angina a result of?

A

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

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3
Q

What is angina most commonly due to?

A

Reduction in coronary blood flow to the myocardium caused by;
obstructive coronary atheroma
coronary artery spasm
coronary inflammation/arteritis

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4
Q

What might cause angina, other than reduction in coronary blood flow to the myocardium?

A

Reduced oxygen transport e.g. anaemia of any cause

Pathologically increased myocardial oxygen demand e.g. left ventricular hypertrophy or thyrotoxicosis

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5
Q

What is the most common cause of angina?

A

Coronary atheroma

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6
Q

When does myocardial oxygen demand increase?

A

In situations where heart rate and blood pressure rise e.g. exercise, anxiety, emotional stress etc.

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7
Q

What is necessary in order for ischaemia to occur?

A

Lumen has to be reduced by more than 70%

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8
Q

What are the non-modifiable risk factors of stable angina?

A 
Age
Gender
Creed 
Family history 
Genetics
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9
Q

What are the modifiable risk factors of stable angina?

A 
Smoking 
Lifestyle e.g. diet and exercise
Diabetes mellitus
Hypertension
Hyperlipidaemia

Good control of diabetes, hypertension and hyperlipidaemia reduce the risk

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10
Q

What are the typical characteristics of angina?

A

Retrosternal site
Described as tight band/pressure/heaviness
May radiate to neck, jaw or down arms
Aggravated by exertion and emotional stress
Relieved by GTN and physical rest

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11
Q

Give some characteristics of pain that make the diagnosis of angina less likely

A 
Sharp/stabbing pain
Associated with normal body movements or respiration
Very localised
Superficial 
No pattern to pain 
Begins some time after exercise
Lasts for hours
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12
Q

What are some cardiovascular differential diagnoses of chest pain?

A

Angina
Aortic dissection
Pericarditis

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13
Q

What are some respiratory differential diagnoses of chest pain?

A

Pneumonia
Pleurisy
Peripheral pulmonary emboli

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14
Q

What are some musculoskeletal differential diagnoses of chest pain?

A

Cervical disease
Costochondritis
Muscle spasm or strain

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15
Q

What are some gastrointestinal differential diagnoses of chest pain?

A 
Gastro-oesophageal reflux 
Oesophageal spasm
Peptic ulceration
Biliary colic
Cholecystitis 
Pancreatitis
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16
Q

If myocardial ischaemia occurs without chest pain, what other symptoms might be present on exercise? Who is this more common in?

A

Breathlessness
Excessive fatigue for the activity undertaken
Near syncope on exertion

More common in the elderly or those with diabetes mellitus

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17
Q

What is the Canadian Classification of Angina Severity (CCS) grading?

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 on walking only 1-2 blocks or 1 flight of stairs

IV – symptoms on any activity, getting washed/dressed causes symptoms

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18
Q

What signs might be seen on examination of a patient with angina?

A 
Tar staining 
Obesity (centripetal) 
Xanthalasma
Hypertension
Abdominal aortic aneurysm bruits 
Absent or reduced peripheral pulses 
Diabetic retinopathy or hypertensive retinopathy
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19
Q

What signs of exacerbating/associated conditions might be seen on examination of a patient with angina?

A

Pallor of anaemia
Tachycardia, tremor, hyper-reflexia or hyperthyroidism
Ejection systolic murmur, plateau pulse of aortic stenosis
Pansystolic murmur of mitral regurgitation
Signs of heart failure e.g. basal crackles, elevated JVP, peripheral oedema

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20
Q

What blood tests are relevant in the investigation of stable angina?

A 
FBC
Lipid profile
Fasting glucose
Electrolytes
Liver function tests
Thyroid function tests
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21
Q

What investigations (other than blood tests) are relevant in the investigation of stable angina?

A 
CXR
Electrocardiogram
Exercise tolerance test
Myocardial perfusion imaging
Cardiac catheterisation/coronary angiography
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22
Q

In what percentage of cases of angina will the electrocardiogram be normal?

A

Over 50%

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23
Q

What might an electrocardiogram show evidence of?

A

Previous MI e.g. pathological Q waves

Left ventricular hypertrophy e.g. high voltages, lateral ST-segment depression

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24
Q

How is an exercise tolerance test useful?

A

Can often confirm the diagnosis of angina

25
Q

When is an exercise tolerance test positive?

A

When patient has typical symptoms and ST-segment depression

26
Q

What does an exercise tolerance test depend on?

A

Ability to walk for long enough to produce sufficient cardiovascular stress

27
Q

What is the prognosis of a negative exercise tolerance test?

A

Doesn’t exclude significant coronary atheroma but if negative at a high workload the overall prognosis is good

28
Q

In what ways is myocardial perfusion imaging superior to exercise tolerance testing?

A

Detection of coronary artery disease
Localisation of ischaemia
Assessing size of area affected

29
Q

What are the disadvantages of myocardial perfusion imaging?

A

Expensive

Involves radioactivity

30
Q

When should myocardial perfusion imaging be used?

A

Where ETT is not possible or is equivocal

31
Q

How does myocardial perfusion imaging work?

A

Exercise or pharmacological agents e.g. adenosine used to produce stress on heart
Radionuclide tracer injected at peak stress on one occasion, images obtained and then this is repeated at rest
Comparison made between stress and rest images

32
Q

What will happen to the radionuclide tracer in a normal myocardium?

A

Normal myocardium will take up the tracer

33
Q

What is indicated if the tracer is seen at rest but not after stress?

A

Ischaemia

34
Q

What is indicated if the tracer is seen neither at rest or after stress?

A

Infarction

35
Q

When is CT coronary angiography useful?

A

To show no or severe coronary disease, not useful for distinguishing mild coronary disease

36
Q

When should invasive angiography be used?

A

Early or strongly positive ETT which suggests multi-vessel disease
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 e.g. drivers

37
Q

What is cardiac catheterisation/coronary angiography useful for?

A

Definition of coronary anatomy with sites, distribution and nature of atheromatous disease which enables decision over what treatment options are possible
Determining whether medication alone or percutaneous coronary intervention should be given

38
Q

What is normally the invasive treatment of choice for angina?

A

Angioplasty and stenting or coronary artery bypass graft surgery

39
Q

What general measures can be taken in the treatment of angina?

A 
Address risk factors e.g. 
BP 
Diabetes mellitus
Cholesterol levels
Lifestyle
40
Q

What is the treatment strategy where symptoms can’t be controlled with medical therapy?

A

Revascularisation with PCI and CABG

41
Q

What drugs can be used in the medical treatment of angina to influence disease progression?

A

Statins
ACEIs
Aspirin

42
Q

How do statins affect angina?

A

Reduce the LDL-cholesterol deposition in atheroma and also stabilise atheroma, reducing plaque rupture and acute coronary syndrome

43
Q

How do ACEIs affect angina?

A

Stabilise the endothelium and reduce plaque rupture

44
Q

How does aspirin affect angina?

A

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

45
Q

What drugs can be used in the medical treatment of angina for symptom relief?

A 
Beta blockers
CCBs - rate limiting and vasodilating
Ik channel blockers
Nitrates
Potassium channel blockers
46
Q

How do beta blockers relieve the symptoms of angina?

A

Help achieve a resting heart rate < 60bpm

Reduce myocardial work and have anti-arrhythmic effects

47
Q

How do CCBs relieve the symptoms of angina?

A

Help achieve resting heart rate < 60bpm

Produce vasodilatation

48
Q

How do Ik channel blockers relieve the symptoms of angina?

A

Help achieve resting heart rate < 60bpm

Ivabradine reduces sinus node rate

49
Q

How do nitrates relieve the symptoms of angina?

A

Produce vasodilatation

50
Q

PTCA and stenting account for what percentage of procedures done?

A

95%

51
Q

What is involved in PTCA and stunting?

A

Stenotic lesions crossed with guidewire and atheromatous plaque flattened into the lumen wall with a balloon and stent

52
Q

What drugs are given to the patient if a stent is used?

A

Aspirin and clopidogrel taken together while the endothelium heals to cover the stent struts until it is no longer seen as a foreign body with associated risk of thrombosis

53
Q

Is PCI an effective treatment?

A

Effective for symptom relief but no evidence to show that it improves prognosis in stable disease

54
Q

What are the risks of procedural complications associated with PCI?

A

0.1% death
02% MI
0.05% emergency CABG
10-15% risk of re-stenosis with bare metal stents
< 10% risk of re-stenosis with drug-eluting stents

55
Q

When is coronary artery bypass graft surgery the best treatment option for stable angina?

A

In diffuse multi-vessel disease

56
Q

What are the risks of procedural complications associated with CABG?

A
  1. 3% death

3. 9% Q-wave MI

57
Q

What is the benefit of CABG?

A

Benefit is long-lasting, with 80% being symptom-free 5 years post-operative

58
Q

What patients derive the most prognostic benefit from CABG?

A

Over 70% stenosis of left main stem artery
Significant proximal three vessel coronary artery disease
Two vessel coronary artery disease that includes significant stenosis of the proximal left anterior descending coronary artery and those who have ejection fraction < 50%

59
Q

What vein is most commonly harvested from the leg for CABG?

A

Long saphenous vein

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