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1st Year Systems > Stable Angina > Flashcards

Stable Angina Flashcards

1
Q

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

A

Obstructive coronary atheroma (Very common)

Coronary artery spasm (Uncommon);

Coronary inflammation/arteritis (Very rare)

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3
Q

What are the uncommon reasons for ahving stable angina?

A

Uncommonly due to :

  • (coronary spasm or artery inflammation)
  • Reduced O2 transport (anaemia of any cause)
  • Pathological increase in myocardial O2 demand (LVH - caused by severe hypertension, significant aortic stenosis and hypertrophic cardiomyopathy) and Thyrotoxicosis - hypermetabolic state.
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4
Q

What is the effect of coronary atheroma on the onset of excersize?

A

Increased myocardial oxygen demand leads to myocardial ischaemia because of the obstructed coronary blood flow - symotoms of angina arise

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5
Q

What situations might cause HR and BP to rise (and therefore myocardial oxygen demand)?

A

Exercise, anxiety/emotional, cold weather, stress and after a large meal.

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6
Q

What is angina felt in the chest called?

A

Angina pectoris

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7
Q

What level of obstruction is present in the lumen in stable angina?

A

Obstructive if over 70% of the lumen

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8
Q

How should the patient describe the site of the pain?

A

Retrosternal

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9
Q

How should the patient describe character of the pain?

A

often tight band/pressure/heaviness

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10
Q

Where can the pain of angina radiate?

A

neck and/or into jaw, down arms

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11
Q

What are the releiving factors for angina?

A

Rest and GTN

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12
Q

When is the pain less likely to be angina?

A

Sharp/‘stabbing’ pain; pleuritic or pericardial.

Associated with body movements or respiration.

Very localised; pinpoint site.

Superficial with/or without tenderness.

No pattern to pain, particularly if often occuring at rest.

Begins some time after exercise.

Lasting for hours.

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13
Q

What are the differential diagnoses for angina?

A

Cardiovascular causes:

Aortic dissection (intra-scapular “tearing”), pericarditis

Respiratory:

Pneumonia, pleurisy, peripheral pulmonary emboli (pleuritic)

Musculoskeletal:

Cervical disease, costochondritis, muscle spasm or strain

GI causes:

Gastro-oesphageal reflux, oesophageal spasm, peptic ulceration, biliary colic, cholecystitis, pancreatitis

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14
Q

What is meant by dissection of aorta?

A

When the inner layer of the aorta tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect).

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15
Q

Define costochondritis

A

an inflammation of the cartilage that connects a rib to the breastbone (sternum). Pain caused by costochondritis might mimic that of a heart attack or other heart conditions

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16
Q

What are peptic ulcers?

A

Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine

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17
Q

Define biliary colic

A

Biliary colic, also known as a gallbladder attack, is when pain occurs due to a gallstone temporarily blocking the bile duct. Typically the pain is in the right upper part of the abdomen and it can radiate to the shoulder. Pain usually lasts from one to a few hours.

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18
Q

Define cholecystitis

A

Inflammation of the Gall bladder

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19
Q

Myocardial ischaemia can occur without chest pain but other symptoms, what are these symptoms?

A

Breathlessness on exertion

Excessive fatigue on exertion for activity undertaken

Near syncope on exertion.

More often in the elderly or those with diabetes mellitus: probably due to reduced pain sensation.

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20
Q

What is the canadian classification for angina severity?

A
  1. Ordinary physical activity does not cause angina, symptoms only on significant exertion.
  2. Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs.
  3. Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs.
  4. Symptoms on any activity, getting washed/dressed causes symptoms.
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21
Q

What are the non-modifiable risk factors for angina?

A

Age, gender, creed, family history & genetic factors

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22
Q

What are the modifiable risk factors for angina?

A

Smoking

Lifestyle - excersize and diet

Diabetes mellitus - glycaemic control reduces CV risk

Hypertension - BP control reduces CV risk

Hyperlipidaemia - lowering reduces CV risk

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23
Q

What are typical signs of people with angina?

A

Tar stains on fingers

Obesity (centripedal(high waist to hip ratio (apple shape)))

Xanthalasma and corneal arcus (cholesterol deposit in the iris) (hypercholesterolaemia)

Hypertension,

Abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses.

Diabetic retinopathy, hypertensive retinopathy on fundoscopy.

24
Q

What are the exacerbating or associated conditions?

A

Pallor of anaemia

Tachycardia, tremor, hyper-reflexia of hyperthyroidism (overactive reflexes)

Ejection systolic murmur, plateau pulse of aortic stenosis

Pansystolic murmur of mitral regurgitation, and

Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema.

25
Q

What are the relevant investigations for angina?

A

Bloods

CXR

Electrocardiogram

EET (Excersize tolerance tests)

Myocardial perfusion imaging

CT coronary angiography

Invasive angiography

26
Q

What do you look out for when measuring bloods?

A

Full blood count, lipid profile and fasting glucose; Electrolytes, liver & thyroid tests would be routine

27
Q

Why would you order a chest X-ray for someone with angina?

A

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

28
Q

In what percentage of cases in an electrocardiogram normal for someone with angina?

A

Over 50% of cases

29
Q

What is the significance of pathological Q waves?

A

Prior myocardial infarction

30
Q

How can you tell Left ventricular hypertrophy from an ECG?

A

High voltages, lateral ST-segment depression or “strain pattern”.

31
Q

What is a positive test for an ETT?

A
32
Q

What is a negative ETT indicative of?

A

Doesn’t exclude significant coronary atheroma but signifies good prognosis if the workload is high

33
Q

Why is moyocardial perfusion imaging superior to ETT in detection of CAD?

A

Better in localising ischaemia and assessing the size of the area affected

BUT - Expensive, involves radioactivity

34
Q

During myocardial perfusion imaging - how is stress applied to the patient?

A

Excersize or pharmacological stress - nadenosine, dipyridamole or dobutamine – these are vasodilators – work on areas that are not affected.

35
Q

How are the results from myocardial perfusino imaging interpreted?

A

Comparison of images at rest and after rest

Tracer seen at rest but not after stress = ischaemia

Tracer seen neither rest, or after stress = infarction

36
Q

When would you use invasive angiography?

A

Early or strongly positive ETT (suggests multi-vessel ds).

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 etc.

37
Q

What are the different types of percutaneous coronary intervention?

A

Angioplasty and stenting or coronary bypass graft (CABG) surgery

38
Q

How is cardiac catheterisation / cornary angiography carried out?

A

Under local anaesthetic

Cannula is inserted into the femoral or radial artery

Coronary catheter is passed into the ostium of the coronary arteries.

Radio-opaque contrast injected down coronary arteries and visualised on X-ray.

(Coronary ostium - Opening of coronary arteries at root of aorta

39
Q

Describe the dye used in invasive angiography.

A

Clear, watery, blood compatible, commonly called an X-ray dye.

Iodinated -

Iodine absorbes xrays – you jest get a picture of the lumen and not the lumen walls

Iodine is normally clear

40
Q

What are the general measures to control angina?

A

Risk factors including Blood pressure, cholesterol, lifestyle and diabetes mellitus

41
Q

If the symptoms are not controlled after general measures and medical treatment, what are the next steps?

A

Revascularisation in symptoms are not controlled.

Percutaneous coronary intervention (PCI) & coronary artery bypass grafting (CABG)

42
Q

What is the medical treatment that influences disease progression?

A

Statins - for high cholesterol (>3.5 mmol/l.)

These reduce LDL-cholesterol deposition in atheroma and also reduce plaque rupture and ACS.

ACE inhibitors if increased CV risk and atheroma

Stabilise endothelium and also reduce plaque rupture.

Aspirin - 75mg or clopidogrel if intolerant of aspirin.

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

43
Q

What is the medical treatment that releives symptoms?

A

Beta blockers - achieve resting hr <60 bpm. Reduced myocardial work and have anti-arrhythmic effects.

Ca2+ channel blockers; achieve resting hr <60 bpm, produce v

Central acting eg diltiazem/verapamil if ß-blockers C-I

Peripherally acting dihydropyridines eg amlodipine, felodipine produce vasodilation

Potassium channel blockers - achieve resting hr <60 bpm.

Ivabridine is a new medication which reduces sinus node rate

Nitrates: Vasdilation - Used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray for immediate use.

44
Q

What is the main procedure carried out in pericutaneous coronary intervention?

A

Pericutaneous transluminal coronary angioplasty and stenting (now in about 95% of procedures)

45
Q

How is the stent applied?

A

SImilar process to coronary angiography - ateromaous plaque is squashed with a balloon and stent

46
Q

What medicine is used after placement of a stent?

A

Aspirin and clopidogrel - whilst endothelim covers the stent struts until it is no longer seen as a foreign body with associated risk of thrombosis

47
Q

What is PCI effective for?

A

Symptoms but no evidence stating that it improves prognosis

48
Q

What are the risks associated with PCI?

A

Death

MI

Emergency coronary artery bypass grafting

Restenosis

49
Q

What is the best option for treatment of someone with diffuse multi-vessel coronary obstruction

A

Coronary artery bypass surgery

50
Q

How do risks compare between pericutaneous coronary intervention and coronary artery bypass grafting?

A

‘Up front’ risks are significantly > PCI

death=1.3%, Q-wave MI=3.9%; these increase in presence of co-morbidity

But good lasting benefit- 80% symptom free 5 years later.

CABG may confer prognostic benefit in certain subgroups:

51
Q

What vein do they normally use in CABG?

A

Long saphenous vein

52
Q

What artery can they use in CABG?

A

Mammary artery

53
Q

Why is the long saphenous vein reversed?

A

So that the valves travel in the correct direction

54
Q

Where is the mammary artery placed?

A

Places the end of the artery beyond the area where the blockage is – usually lasts the lifetime of the patient

55
Q
A

1st Year Systems (81 decks)

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