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Cardiovascular block > SIHD and angina > Flashcards

SIHD and angina Flashcards

1
Q

What is angina ?

A

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

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2
Q

What is the most common cause of angina ?

A

Coronary atheroma

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3
Q

What are the most common ways coronary blood flow to the myocardium is reduced ?

A

Obstructive cornonary atheroma (v common)
Spasm of a portion of cornonary artery (uncommon)
Abnormal coronary flow (uncommon)

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4
Q

What are the uncommon reasons for having stable angina ?

A

Uncommonly due to reduced O2 transport:
- anaemia of any cause
Uncommonly due to the pathologically increased myocardial O2 demand:
- LVH caused by years of persistant hypertension, significant aortic stenosis or
hypertrophic cardiomyopathy
- Thyrotoxicosis

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5
Q

What is essential in the history of angina ?

A

Characteristics of pain to differenciate from other causes of chest pain

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6
Q

Where is the site of angina usually ?

A

Retrosternal

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7
Q

What is the character of chest pain usually ?

A

Often tight band/pressure/heaviness

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8
Q

Where does the pain usually radiate ?

A

Neck and jaw and down arms

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9
Q

What are the aggravating factors of chest pain ?

A

Exertion

Emotional stress

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10
Q

What is the releveling factors of anginal chest pain ?

A

Rapid improvement with GTN

Physical rest

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11
Q

What are the features that make it less likely to be angina ?

A 
Sharp/stabbing pain: pleuritic or pericardial Associated with body movements or respiration 
Very localised
Superficial with or without tenderness
No pattern to pain
Begins some times after exercise
Lasting for hours
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12
Q

What symptoms on exertion is often assocaited with myocardial ischameia with no chest pain ?

A

Breathlessness on exertion
Excessive fatigue on exertion for activity undertaken
Near syncope on exertion

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13
Q

What are the differential diagnosis of chest pain ?

A 
Cardiovascular causes:
         - aortic dissection, pericarditis 
Respiratory:
	 - pneumonia 
	 - pleurisy
	 - peripheral pulmonary emboli
Musculoskeletal:
	 - cervical disease
	 - costochondritis
	 - muscle spasms or strain 
GI causes:
	 - gastro-oesphageal reflux
         - oesphageal spasm
         - peptic ulceration
         - biliary colic
         - cholecystitis 
         - pancreatitis
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14
Q

What does a CCS score of I mean ?

A

Ordinary physical activity does not cause angina, symptoms only on significant exertion

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15
Q

What does a CCS score of II mean ?

A

Slight limitation of ordinary activity, symptoms on walking 2 blocks or >1 flight of stairs

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16
Q

What does a CCS score of III mean ?

A

Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs

17
Q

What does a CCS score of IV mean ?

A

Symptoms on any activity, getting washed/dressed causes symptoms

18
Q

What are the non-modifiable risk factors for coronary artery disease and ASCVD ?

A 
Age 
Gender (M>F)
Creed
Family history 
Genetic factors
19
Q

What are the modifiable risk factors for coronary artery disease and ASCVD ?

A

Smoking
Lifestyle- exercise and diet
Diabetes mellitus (glycaemic control reduces CV risk)
Hypertension (BP control reduces CV risk)
Hyperlipidaemia (lowering reduces CV risk)

20
Q

What are the common examination findings ?

A 
Tar stains on fingers
Obesity (centripetal)
Xanthelasma and corneal arcus (hypercholesterolaemia)
Hypertension
Abdominal aortic aneurysm
Arteial bruits 
Absent or reduces peripheral pulses
Diabetic retinopathy, hypertensive retinopathy on fundoscopy
21
Q

What are the signs of exacerbating or associated conditions ?

A

Pallor or anaemia
Tachycardia, tremor, hyperreflexia of hyperthyroidism
Ejection systolic murmur, plateau pulse of aortic stenosis
Pansystolic murmur of mitral regurgitation
Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema

22
Q

What investigations can be done ?

A 
Bloods
CXR
ECG
Exercise tolerance test 
Myocardial perfusion imaging 
CT coronary angiogram
23
Q

What blood test might be done ?

A

FBC
Lipid profile and fasting glucose
Electrolytes
Liver and thyroid tests

24
Q

What would we look for in a CXR ?

A

Often helps show other cause of chest pain and can help show pulmonary oedema

25
Q

What might an ECG be like in angina ?

A

Normal in over 50% of cases
May be evidence of prior MI i.e. Pathological Q-waves
May be evidence of LVH i.e. High voltages, lateral ST-segment depression or ‘strain pattern’

26
Q

What is the purpose of an exercise tolerance test ?

A

Often can conform diagnosis of angina
Relies on ability to walk for long enough to produce sufficient CV stress
Typical symptoms and ST-segment depression for positive test
Negative ETT doesnt exclude significant cornonary atheroma but if negative at high workload overall prognosis is good

27
Q

What might myocardial perfusion imaging show ?

A

Superior to ETT in detection of CAD, localisation of ischaemia and assessing size of area affected
Expensive, involves radioactivity: depending on availability used where ETT not possible/equivocal
Either exercise or pharmacological stress: adenosine, dipyridamole or dobutamine
Radionuclide tracer injected at peak stress on one o

28
Q

When might a tracer be seen at rest but not after stress ?

A

Ischaemia

29
Q

When will a tracer never be seen at rest or after stress ?

A

Infarction

30
Q

Why is CT angiography useful ?

A

Possible to image arteries well
They will be moving al the times- limitation
More accurate in pateints with low HR and normal sinus rhythm

31
Q

When should invasive angiography be used ?

A

Early or strongly positive ETT (suggests multi-vessel ds)
Angina refractory to medical history
Diagnosis not clear after non-invasive medical therapy
Young cardiac pateint due to work/life effects
Occupation or lifestyle with risk e.g. Drivers

32
Q

What can cardiac catheterisation/ coronary angiogram show in chronic stable angina ?

A

Definition of coronary anatomy with sites, distribution and natures of atheromatous disease enables decision over what treatment options are possible
Whether medication alone or percutaneous coronary intervention (PCI) most often angioplasty and stenting or coronary artery bypass graft (CABG) surgery
Almost always done under local anaesthetic
Arterial cannula inserted into femoral or radial artery
Cornonary catheters passes to aortic root and introduced into the ostium of coronary arteries
Radio-opaque contrast injected down coronary arteries and visualised on x-ray

33
Q

What are the general measures of treatment for angina ?

A

Address ASCVD risk factors: BP, DM, cholestrol

Lifestyle: physical activity

34
Q

What drugs can be used to influence disease progress ?

A

Statins: consider if total cholestrol >3.5mmol/L
- reduces LDL-cholestrol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS
ACEI: if increased CV risk and atheroma
- stabilises endothelium and also reduces plaque rupture
Aspirin: 75mg or clopidogrel if intolerant of aspirin
- may not directly affect plaque but does protect endothelium and reduces of platelet activation/aggregation

35
Q

What drugs can be used for symptom relief of angina ?

A

B-blockers: acheive resting HR <60bpm
- reduced myocardial work and have anti-arrhythmic effects
Ca2+ channel blockers: acheive resting HR <60bpm
- central acting e.g. Diltiazem / verapamil if B-blockers contraindicated
Ca2+ channel blockers: produce vasodilation
- peripherally acting dihydropyridines e.g. Amlodipine, felodipine
Ik channel blockers: acheive resting HR < 60bpm
- ivabradine reduces sinus node rate
Nitrates: produces vasodilatation:
- used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray
K+ channel blockers: nicorandil
- nitrate molecule and K channel helpful in pre-conditioning

36
Q

Is symptoms are not controlled what else can be undertaken ?

A

Revascularisation:

  • percutaneous coronary intervention (PCI)
  • CABG

Cardiovascular block (28 decks)

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