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General med - Cardiovascular > Angina > Flashcards

Angina Flashcards

(60 cards)

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1
Q

What causes angina

A

Narrowing of the coronary arteries reduces blood flow to the myocardium

During times of high demand such as exercise, there is insufficient supply of blood to meet demand

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2
Q

What is stable angina

A

Angina is stable when symptoms are always relieved by rest or GTN

Unstable when symptoms come on randomly whilst at rest considered ACS

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3
Q

IX for stable angina

A

CT coronary angiography - involves injecting contrast and taking CT images timed with the heart beat to highlight any narrowing

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4
Q

General management of stable angina(RAMP)

A

Refer to cardio(urgently if unstable)

Advise about diagnosis, management and when to call ambulance

Medical treatment

Procedural or surgical interventions

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5
Q

Immediate symptomatic relief of stable angina

A

GTN spray –> vasodilation

Take GTN, then repeat after 5 mins. If there is still pain 5 mins after the repeat dose –> ambulance

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6
Q

Long term symptomatic relief of stable angina

A

Beta blocker(bisoprolol 5mg OD)

Ca2+ blocker(amlodipine 5mg OD)

Other options not first line:

Long acting nitrates(isosorbide mononitrate)
Ivabradine
Nicorandil
Ranolazine

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7
Q

Secondary prevention of stable angina

A

Aspirin(75mg OD)
Atorvastatin 80mg OD
ACE inhibitor

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8
Q

Surgical interventions for angina

A

PCI with coronary angioplasty(dilating the blood vessel with a balloon and/or inserting a stent)

CABG(severe stenosis)

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9
Q

What does PCI involve

A

Involves catheter into the patient’s brachial or femoral artery, feeding that up to the coronary arteries under xray guidance and injecting contrast

Any areas of stenosis are highlighted on xray images which can be treated with balloon dilatation followed by insertion of a stent

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10
Q

What does coronary artery bypass graft(CABG) involve

A

Opening the chest along the sternum(midline sternotomy scar)

Taking a graft vein from the patient’s leg(usually great saphenous vein) and sewing it on to the affected coronary artery to bypass the stenosis

Recovery is slower and complication rate is higher than PCI

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11
Q

What is ACS usually due to

A

Thrombus from an atherosclerotic plaque blocking a coronary artery

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12
Q

What are the three types of ACS

A

Unstable angina
STEMI
NSTEMI

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13
Q

What does the left coronary artery become

A

Circumflex and LAD

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14
Q

What does the right coronary artery supply

A

Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area

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15
Q

What does circumflex artery supply

A

Left atrium

Posterior aspect of left ventricle

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16
Q

What does LAD supply

A

Anterior aspect of left ventricle

Anterior aspect of septum

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17
Q

Diagnosis of ACS

A

ECG

  • ST elevation or new left bundle branch block –> STEMI
  • Raised troponin + other ECG changes(ST depression, T wave inversion, pathological Q waves)–> NSTEMI
  • Normal tropi levels and no ECG changes –> unstable angina or MSK pain
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18
Q

Symptoms of ACS

A 
Nausea and vomiting 
Sweating and clamminess 
Feeling of impending doom 
SOB 
Palpitations 
Pain radiating to jaw or arms
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19
Q

What does silent MI refer to

A

Diabetic patients may not experience typical chest pain during ACS

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20
Q

What do pathological Q waves indicate

A

Suggest a deep infarct - a late sign –> NSTEMI

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21
Q

Heart area and ECG leads - left coronary artery

A

Anterolateral

I, aVL, v3-6

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22
Q

Heart area and ECG leads - LAD

A

Anterior

V1-4

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23
Q

Heart area and ECG leads - circumflex

A

Lateral

I, aVL, V5-6

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24
Q

Heart area and ECG leads - Right coronary artery

A

Inferior

II, III, aVF

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25
What are troponins
proteins in cardiac muscle Diagnosis of ACS usually requires serial troponins Rise in troponin is consistent with myocardial ischaemia as proteins are released from ischaemic muscle
26
Alternative causes of raised tropi
``` Chronic renal failure Sepsis Myocarditis Aortic dissection PE ```
27
Acute STEMI treatment
``` Primary PCI(if available within 2 hrs) Thrombolysis(if PCI not available within 2 hrs) ```
28
What does thromobolysis involve
Injecting a fibrinolytic medication(alteplase) to dissolve clots Significant risk of bleeding
29
Acute NSTEMI treatment BATMAN
``` Beta blockers Aspirin 300mg Ticagrelor Morphine Anticoagulant(fondaparinux) Nitrates ``` Oxygen only if stats below 95%
30
Scoring system to assess for PCI in NSTEMI
GRACE score - gives 6 month risk of death or repeat MI after nstemi If medium or high risk, they are considered for early PCI
31
Complications of MI (DREAD)
``` Death Rupture of heart septum or papillary muscles Edema(heart failure) Arrhythmia and Aneurysm Dressler's syndrome ```
32
What is dressler's syndrome
Post-MI syndrome | Occurs around 2-3 weeks after an MI
33
What causes dressler's syndrome post-MI
localised immune response which causes pericarditis
34
How does dressler's syndrome present
Pleuritic chest pain Low grade fever Pericardial rub and auscultation
35
Diagnosis of dressler's syndrome
ECG(global ST elevation and T wave inversion) Echocardiogram Raised inflammatory markers(CRP and ESR)
36
Management of dressler's syndrome
NSAIDs(Aspirin/ibuprofen) Steroids(predisolone) in more severe cases Paricardiocentesis
37
Secondary prevention medical management of ACS - 6 A's
Aspirin 75mg OD Atiplatelet(clopidogrel or ticagrelor for up to 12 months) Atorvastatin 80 mg OD ACE inhibitors(ramipril) Atenolol Aldosterone antagonist for those with clinical heart failure(eplerenone)
38
Secondary prevention lifestyle measures - ACS
``` Smoking cessation Reduce alcohol consumption Mediterranean diet Cardiac rehab Optimise management of other co-morbidities(Diabetes and hypertension) ```
39
Triggers of acute left ventricular failure
Iatrogenic(agressive IV fluids in frail elderly patient) Sepsis MI Arrhythmias
40
Presentation of acute LVF
Rapid onset SOB Exacerbated by lying flat and improves on sitting up Type 1 resp failure Cough(frothy white/pink sputum)
41
Examination findings in acute LVF
``` Increased resp rate Reduced O2 sats Tachycardia 3rd heart sound Bilateral basal crackles Hypotension in severe cases ```
42
What is BNP
Is a hormone that is released from the heart ventricles when myocardium is stretched beyond normal range
43
What is the action of BNP
To relax the smooth muscle in blood vessels to reduce systemic vascular resistance making it easier for heart to pump blood through the system BNP also acts on kidneys as a diuretic
44
Other causes of raised BNP besides heart failure
``` Tachycardia Sepsis PE Renal impairment COPD ```
45
What is the main measure of left ventricular function
Ejection fraction(percentage of blood in the left ventricle that is pumped out with each ventricular contraction) Fraction above 50% is considered normal
46
CXR findings in LVF
``` Cardiomegaly(defined as cardiothoracic ratio?0.5) Upper lobe diversion Bilateral pleural effusions Fluid in interlobar fissures Fluid in septal lines(kerley lines) ```
47
Management of acute LVF(Pour SOD)
Pour away(stop) IV fluids Sit up Oxygen(if < 95%) Diuretics
48
Other management options in severe acute pulmonary oedema or cardiogenic shock
IV opiates(act as vasodilators) Non-invasive ventilation(NIV) Continuous positive airway pressure(CPAP) Inotropes(noradrenalin)
49
Which type of MIs are more likely to result in AV block
Inferior MI
50
What can cause a left ventricular aneurysm following an MI
The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation.
51
What is a left ventricular aneurysm typically associated with
Persistent ST elevation and left ventricular failure Thrombus may form within aneurysm requiring anticoagulation
52
How might patients with left ventricular free wall rupture present
Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.
53
Which type of MIs more commonly cause acute mitral regurgitation
More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle.
54
Features of acute mitral regurgitation following an MI
Acute hypotension and pulmonary oedema may occur. An early-to-mid systolic murmur is typically heard. Patients are treated with vasodilator therapy but often require emergency surgical repair.
55
Criteria for stable angina
chest pain is described as sharp (rather than constricting) chest pain may be precipitated by physical exertion chest pain is relieved by GTN spray within 5 minutes
56
When should oxygen be given for ACS
do not routinely give oxygen, only give if sats < 94%
57
Immediate management of suspected ACS
GTN Aspirin 300mg Oxygen if required ECG asap
58
Definition of atypical angina
NICE define anginal pain as the following: 1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms 2. precipitated by physical exertion 3. relieved by rest or GTN in about 5 minutes patients with all 3 features have typical angina patients with 2 of the above features have atypical angina
59
1st line ix for patients in whom stable angina cannot be excluded by clinical assessment alone
CT coronary angiography
60
Which features make atypical ACS presentation more likely
Being elderly, diabetic or female

General med - Cardiovascular (13 decks)

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