angina

Question 1

pathophysiology

Answer 1

mismatch between supply of O2 and metabolite to myocardium and myocardial demand for them

most commonly due to reduction in CA blood flow to myocardium

uncommonly due to reduced O2 transport (anaemia of any cause) or increased myocardial O2 demand (LV hypertrophy / thyrotoxicosis)

Question 2

define angina

Answer 2

” a discomfort in chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis “

Question 3

types

Answer 3

stable

unstable

Question 4

risk factors

Answer 4

modifiable: smoking, lifestyle - exercise/diet, HTN, hyperlipidaemia, diabetes

non-modifiable: age, gender, genetics, FH

Question 5

aetiology

Answer 5

coronary atheroma!!!
when there is increased O2 demand for myocardium, increased blood flow is obstructed and this leads to myocardial ischaemia -> anginal symptoms

Question 6

symptoms

Answer 6

CHEST PAIN
sob
fatigue

Question 7

signs

Answer 7

tar stains on fingers
tachycardia 
obesity
absent/reduced peripheral pulses 
diabetic retinopathy 
xanthalasma and corneal arcus 

pallor anaemia

HF: basal crackles, elevated JVP, peripheral oedema

Question 8

differential CVS diagnoses

Answer 8

aortic dissection, pericarditis

Question 9

other differential diagnoses

Answer 9

GI: reflux, pancreatitis
resp: pleurisy, pneumonia, peripheral pulmonary emboli
MSK: cervical disease, costochondritis

Question 10

bedside tests

Answer 10

ECG

history

Question 11

blood tests

Answer 11

FBC
lipid profile & fasting glucose
liver & thyroid
electrolytes

Question 12

imaging

Answer 12

CXR - can show other causes and show pulmonary oedema
myocardial perfusion
CT coronary angiography

Question 13

medical management for influencing disease progression

Answer 13

Statins - consider if total cholesterol >3.5mmol/l

ACE inhibitors - if increased CV risk and atheroma

Aspirin - 75mg or clopidogrel if intolerant of aspirin

Question 14

medical management for relief of symptoms

Answer 14

GTN spray

Beta blockers - achieve resting hr <60bpm

CCB - achieve resting hr <60bpm, produce vasodilatation

Ik channel blockers - achieve resting hr <60bpm - ivabridine

Nitrates - produce vasodilatation

K+ channel blockers - nicorandil

Question 15

percutaneous coronary intervention

Answer 15

similar beginnings to coronary angiography but cross stenotic lesion with guidewire and squash atheromatous plaque into the arterial walls with balloon and stent

effective for symptoms
no evidence for improving prognosis

risk of restenosis

Question 16

coronary artery bypass grafting (CABG)

Answer 16

often best option for stable angina
‘up front’ risks > PCI
good lasting benefit - 80% symptom free 5yrs later

patients must continue disease modifying medication and predictable deterioration in vein grafts after 10yrs

Question 17

stable angina

Answer 17

attacks have a trigger ie stress or exercise , stop within few mins of resting

Question 18

unstable angina

Answer 18

attacks more unpredictable - may not have trigger - can continue despite resting