Stable Ischaemic Heart Disease (SIHD) and Angina

Question 1

What is the DEFINITION of ANGINA?

Answer 1

1) Discomfort/Pain Chest and/or Adjacent Areas
2) Associated with Myocardial Ischaemia

*No Myocardial Necrosis

Question 2

Describe the PATHOPHYSIOLOGY of STABLE ANGINA (SA):

Answer 2

Mismatch Between Supply of O2 and Metabolites to the Myocardium and the Myocardial Demand for Them

Question 3

What are the UNCOMMON CAUSES of SA?

Answer 3

1) Coronary Artery Spasm
2) < O2 Transport, i.e. Anaemia
3) > Myocardial O2 Demand, i.e. Left Ventricular Hypertrophy (LVH)

Question 4

What is the MOST COMMON CAUSE of SA?

Answer 4

< Coronary Blood Flow due to Obstructive Atheroma

Question 5

When are SA SYMPTOMS MANIFESTED?

Answer 5

Only on Exertion

Question 6

What are some of the PRECIPITANTS for SA CHEST PAIN?

Answer 6

1) Exercise
2) Cold Weather
3) Emotional Stress
4) After a Large Meal

Question 7

What DIAGNOSTIC TOOL can be used to ASSESS the SEVERITY of Angina?

Answer 7

Canadian Classification of Angina Severity (CCS)

Question 8

What are the NON-MODIFIABLE RISK FACTORS for Coronary Artery Disease?

Answer 8

1) Age
2) Gender
3) Race
4) Family History
5) Genetic Factors

Question 9

What are the MODIFIABLE RISK FACTORS for Coronary Artery Disease?

Answer 9

1) Smoking
2) Lifestyle - Exercise and Diet
3) Diabetes Mellitus (Better Glycaemic Control)
4) Hypertension (BP Control)
5) Hyperlipidaemia (< Cholesterol)

Question 10

What are the SYMPTOMS of SA?

Answer 10

Exertional Chest Pain/Discomfort

Can also present with the following, in the Absence of Chest Pain

• Exertional Dyspnoea
• Excessive Exertional Fatigue
• Exertional Presyncope

Question 11

Describe some of the CHARACTERISTICS of SA CHEST PAIN:

Answer 11

Site - Retrosternal

Onset - Sudden

Character - Tight Band/ Pressure

Radiation - Neck and/or Jaw; Down the Arms

Question 12

What are some of the SIGNS of SA?

Answer 12

1) Tar Staining of Fingers
2) Obesity
3) Xanthalasma
4) Corneal Arcus
5) Hypertension
6) Absent/< Peripheral Pulses
7) Abdominal Aortic Aneurysm
8) Arterial Bruits

Question 13

What INVESTIGATIONS would be used to diagnose SA?

Answer 13

1) FBCs - Serum Biochemistry (Lipid Profile and Fasting Glucose; U and Es, LFTs and Thyroid)
2) CXR
3) ECG
4) Exercise Tolerance
5) Myocardial Perfusion Scanning
6) CT-Coronary Angiography
7) Invasive Angiography
8) Cardiac Catheterisation/Coronary Angiography

Question 14

What would be EXPECTED on ECG from a patient, with SA, subjected to EXERCISE?

Answer 14

ST-Segment Depression

Question 15

What PHARMACOLOGICAL TREATMENT would ALLIEVIATE the SYMPTOMS of SA RAPIDLY?

Answer 15

Glyceryl Trinitrate (GTN)

Question 16

What MANAGEMENT STRATEGIES can be employed to TREAT SIHD and Angina?

Answer 16

1) General Measures
- Address Risk Factors: BP; DM; Cholesterol and Lifestyle
2) Medical Treatment
- Drugs to < Disease Advancement and Symptoms
3) Revascularisation, i.e. PCI and CABG

Question 17

What MEDICAL TREATMENTS can be used to attenuate SIHD and SA DISEASE PROGRESSION?

Answer 17

1) Statins, i.e. Simvastatin
2) ACEIs
3) Aspirin (Clopidogrel, if Intolerant of Aspirin)

Question 18

What MEDICAL TREATMENTS can be used for RELIEF of SIHD SYMPTOMS?

Answer 18

1) Beta-Blockers, i.e. Bisoprolol and Atenolol
2) CCBs, i.e. Amlodipine
3) “Funny” Channel Blockers, i.e. Ivabradine
4) Nitrates, i.e. GTN Spray
5) K+ Channel Agonist, i.e. Nicorandil

Question 19

If symptoms of SIHD or SA are NOT RELIEVED/RESOLVED by general and medical measures, what are the NEXT STEPS in MANGEMENT?

Answer 19

Revascularisation

1) Percutaneous Coronary Intervention (PCI) and Stenting
2) Coronary Artery Bypass Grafting (CABG)

Question 20

What are the MAIN PHYSIOLOGICAL MECHANISMS that are ATTENUATED by pharmacological therapy in SIHD and Angina?

Answer 20

Cardiac Workload:

1) Heart Rate
2) Myocardial Contractility
3) Afterload

Question 21

What does the ‘REBOUND PHENOMENON’ in BETA-BLOCKER use constitute?

Answer 21

Sudden Cessation of Beta-Blockers may Precipitate an MI

*< Dose of Beta-Blockers Over a Week or Two

Question 22

What are the MAIN CONTRAINDICATIONS to Beta-Blocker use for SIHD and Angina?

Answer 22

1) Asthma
2) Heart Failure
3) Bradycardia/Heart Block
4) Raynaud’s Syndrome
5) PVD

Question 23

What are the DANGERS of using NIFIDEPINE IMMEDIATE RELEASE as a treatment for CVS disease?

Answer 23

Rapidly Acting Vasodilatatory-CCB that May Precipitate Acute MI or Stroke

Contraindications

• Post MI
• Unstable Angina

Question 24

What TREATMENTS are the “MAIN-STAYS” in UNSTABLE ANGINA?

Answer 24

IV Nitrates + LMWH

Question 25

What are the ADVERSE DRUG REACTIONS caused by NITRATES?

Answer 25

1) Headache
2) Hypotension
- GTN Syncope (Sig. in the Elderly; > Falls Risk)

Question 26

Why should LOW DOSE ASPIRIN be used in slow the progression of Chronic SA, particularly in the ELDERLY?

Answer 26

Common Cause of GI Bleed