30. Angina

Question 1

What are the 2 main causes of angina, and what conditions underlie these causes?

Answer 1

1) decrease in myocardia O₂ supply due to:

coronary artery disease (atherosclerosis, spasm, post radiation therapy), severe anaemia -> ischaemia

2) increase in myocardial O₂ demand due to:

L. ventricular hypertrophy (hypertension, aortic stenosis/regurgitation, hypertrophic cardiomyopathy), R. ventricular hypertrophy (pulmonary hypertension/stenosis), rapid tachyarrhythmias (typically AF)

Bold = most common

Question 2

What are the 5 indications for specialist cardiological referral?

Answer 2

1) new onset angina
2) exclusion of angina in high risk individuals with atypical symptoms e.g. hyperlipidaemia
3) worsening angina in pt with previously stable symptoms
4) new/recurrant angina in pt with history of MI/coronary revascularisation (bypass/angioplaty)
5. assessment of occupational fitness (e.g. airline pilots)

Question 3

What is the first diagnosis process for angina?

What is the second diagnosis process for angina?

Answer 3

First: HISTORY!!!!

character, location, radiation (e.g. throat, jaw, arm), duration (if all day, not angina), provocation (angina provoked by exertion, sometimes stress)0

Second: Noninvasive investigation = exercise ECG

Question 4

What is the 4 step process of ischaemia testing for coronary artery disease?

Answer 4

1. Perfusion abnormality = perfusion imaging
2. Regional diastolic and systolic dysfunction = LV wall motion analysis
3. Global LV dysfunction and ischaemic ST depression = eletrocardiography
4. Angina = clinical assessment

Question 5

What might you see in an exercise ECG for angina:

a) diagnostic features?
b) prognostic features?

What kinds of imaging can be used for angina diagnosis?

Answer 5

a) planar or down-sloping ST depression
b) poor exercise tolerence, severe/early ST depression, exertional arrhythmia/hypertension

BUT NOT V. GOOD TEST: false +ve/-ves

Functional imaging: isotope/MR perfusion imaging, dobutamine stress echo

Anatomical imaging: CT calcium scoring and angiography

Question 6

Does stenting for angina prolong life?

What are the 2 types of CABG?

What should you consider before CABG?

Answer 6

No but does help angina.

Bypass using internal mammary artery (for LAD) or saphenous vein (for RCA)

Coronary anatomy, pt choice, proceedural risk (death, stroke, AMI), symptomatic benefit, repeat revasc, prognostic benefit