Stable Isheamia Heart Disease - Presentation and Investigation Flashcards
Define Angina
Stable angina is a discomfort in the chest or adjacent areas associated with myocardial ischaemia but without myocardial necrosis. Symptoms occuring on activity.
Pathophysiology of Angina
Most common cause of angina is coronary atheroma and obstructive coronary artery disease. There is no obstruction to coronary arteries at rest and symptoms come on when there is an increased myocardial oxygen demand, principally on physical activity. This then leads to myocardial ischaemia and that leads to the sensation and symptoms. Can also develop this when at rest due to stress/anxiety
History taking of Angina
- Site of Pain: Retrosternal (heaviness and tightness)
- Character of pain: Often tight band/pressure/heaviness
- Radiation site of pain: Not everyone has radiation of pain but it is common that it may go to neck and/or jaw, down arms
- Cardial feature is symptoms may get worse during increased myocardial oxygen demand Principally physical activity such as walking
What features that make it less likely to be myocardial ischaemia?
- Sharp stabbing pain; pleuretic or pericardial
- Very localised chest pain - pin pointed by patient with finger at partiular area of the chest
- Pain associated with tenderness over the chest wall
- No pattern to the pain, particularly if it is occuring at rest
- Symptoms lasting for hours at the same intensity
What are the non-modifiable risks of coronary artery disease?
- age
- creed
- gender
- family history
- genetic factors
What are the modifiable risks of coronary artery disease?
- Smoking
- Lifestyle - exercise and diet
- Diabetese mellitus
- hypertension
- hyperlipideamia
What are signs of exaccberated symptoms ?
- Tar stains on fingers
- obesity
- Xanthalasma and corneal arcus (hypercholestoreamia)
- Hypertension
What are signs of exaccberated symptoms ?
- Pallor of aneamia
- Tachycardia, tremor, hyperflexia and hyperthyroidism
- Signs of heart failure such as having basal crackles, elevated JVP or peripheral oedema
What are the Baseline investigations done?
- Blood tests
- ECG
What are the non-invasive specialist investigations ?
- Exercise tolerance test - will show ST depression (this test is not that accurate)
- Myocardial perfusion imaging - Tracer seen at rest but not after stress = ischaemia, tracer seen neither at rest or after stress = infarction
- CT Scan of coronary Arteries
- Echo stress ultrasoun
What are the invasive specialist investigations?
- Invasive Angiography
- Cardiac Catheterisation/ coronary angiography
What are the treatment strategies of Stable Angina ?
- General measures. This includes addressing the atheroscelerotic cardiovascular disease factors (ASCVD). Changes in lifestyle such as smoking cessation
- Medical Treatment. This involves drugs to reduce disease progression and symptoms
- Revascularisation (if symptoms are not controlled antianginal medication). Coronary artery bypass grafting can be done
What medical treatment is given influencing disease progression?
Statins: Lower cholestorol. Protect coronary arteries and other arteries of the body. They stabilise coronary plaques
- ACE Inhibitors have a very small effect on the disease. Can stabilise endothelium
- Aspirin doesnt change atheromatous disease but do have a beneficial effect on reducing acute coronary events. Inhibition of platelets reduce the activation of platelets when there is plaque rupturing events and plaque healing.
What medical treatment is given for releif of symptoms
- Beta blockers: Reduce myocardial work and have anti arrythmic effects. Aim to reduce heart rate down to 60 bpm
- Calcium Channel blockers. Aim to reduce patients resting heart rate to 60bpm.
- Ik Channel blockers. Aim to achieve resting heart rate of 60 bpm or less. Do not effect blood pressure as beta blockers and calcium channel blockers do. The effect the sinus node alone to produce a low heart rate.
- Nitrates - Includes GTN spray. Produces vasodilation.
- Potassium channel blocker nicorandil. It has nitric portion to the molecule and potassium activiating channel portion.
What is given to patiens still experiencing symptoms ?
Patients who are still experiencing symptoms will need coronary vascularisation will be required. This can be down in two ways:
- Percataneous coronary intervention
- Coronary Artery Bypass Surgery. Used in patients who have mutli vessel coronary disease
