Angina

Question 1

What is angina?

Answer 1

• cardiac chest pain

- discomfort in chest associated with myocardial ischaemia but without myocardial necrosis

Question 2

Describe the mechanism of angina

Answer 2

• mismatch between supply of O2 and metabolites to myocardium and myocardial demand for them
• normally due to reduction in coronary BF to the myocardium

Question 3

Causes of stable angina

Answer 3

• obstructive coronary atheroma
• coronary artery spasm ( uncommon)
• coronary inflammation/artertisi(rare)
• reduced O2 transport ( anaemia) [ uncommon]
• pathologically increased myocardial O2 demand ( LVH, significant aortic stenosis and hypertrophic cardiomyopathy)
• Thyrotoxicosis

Question 4

Most common cause of atheroma

Answer 4

• coronary atheroma
• On activity? with the increased mycardial O2 demand, obstructed coronary blood flow leads to myocardial isachaemia then symproms of angina
• myocardial O2 demand increases in situations where HR and BP rise; excercise, anxiety/emotional stress after a big meal

Question 5

Stable angina

Answer 5

• myocardial isachaemia causing angina pectoris
• precipitated by excess myocardial O2 demand ( exertion, cold weather, emotional stress, after heavy meal)
• pain in LHS chest region, and left arm

Question 6

Site, character, radiation sites of pain - Stable angina

Answer 6

site ; retrosternal
character of pain = tight band/pressure/heaviness
radiation sites; neck and/or jaw, down arms

Sometimes on extertion:

• breathlessness
• excessive fatigue on exertion for activity taken
• near syncope(faint) on exertion

More often in the elderly or those with diabetes mellitus: probably due to reduced pain sensation. ?
SHOULDNT BE
-localised pain
-lasting for hours
-sharp stabbing pain ( pleuritic/pericardial)
-assoc with body movements/

Question 7

Relieving factors of stable angina

Answer 7

-rapid improvement with GTN/physical rest

Question 8

Differential diagnoses for chest pain

Answer 8

Cardiovasular causes:
aortic dissection, pericarditis

Respiratory: pmeumonia, pleurisy, peripheral pulomary emboli ( pleuritic)

Muscoskeletal: cervical disease, costochrondritis, muscle spasm, strain

GI causes: gastro-oesophageal reflux, osophageal spasm, peptic ulceration, bilary colic, cholecytitis, pancreatitis

Question 9

Risk factors for coronary artery disease

Answer 9

• age, gender, creed?, FX, genetic factors
• Smoking, lifestyle (diet/excercise), diabetes mellitus( glycaemic control reduces CV risk), hypertension (BP control ‘’’’) , hyperlipidaemia ( lowering reduces risk)

Question 10

Stable angina - Examination

Answer 10

• tar staining of fingers
• obesity (centripedal ), Xanathalasma and corneal arcus ( hypercholesetrolaemia)
• hypertension, abdominal aortic aneurysm arterial bruits, absent/reduced peripheral pulses
• diabetic retinopathy, hypertensive retinopathy on fundocscopy?

Question 11

Signs of exaceerbating/associated conditions

Answer 11

• pallor of anemia
• tachycardia, tremor, hyper-reflexia of hyperthyroidism
• ejection systolic murmur, plateau pulse of aortic stenosis
• pansystolic murmur of mitral regurgitation
• signs of HF ( basal crackles, elevated JVP, peripheral oedema)

Question 12

Investigations for stable angina

Answer 12

• Bloods
• CXR
• electrocardiogram
• excercise tolerance test ( ETT)
• myocardial perfusion imaging
• CT coronary angiography

-cardiac catherterisation/cornorary angiography

Invasive angiography if:

• early/postiive ETT ( suggests multi vessel ds?)
• angina refractory to medical therapy
• daignosis not cear after non-invasive tests
• young cardiac patients work
• occupation/lifestyl with risk ( dirvers etc)

Question 13

Investigations of stable angina - Bloods

Answer 13

• FBC
• lipid profile
• fasting glucose
• electrolytes
• liver and thyroid tests

Question 14

Investigations of stable angina - CXR

Answer 14

may show pulmonary oodema/other causes of pain

Question 15

Investigations of stable angina :Electrocardiogram

Answer 15

• evidence of prior myocardial infarction ( ie pathological Q-waves)
• evidence of left ventricular hypertrophy ( ie high voltages, lateral ST-segment depression/ ‘‘strain pattern’’

Question 16

Investigations of stable angina - excercise tolerance test

Answer 16

• walking to produce sufficient CV stress

- if negative at high workload, prognosis is good

Question 17

Investigations of stable angina - myocardial perfusion imaging

Answer 17

• can detect CAD, localise isachaemia + assess size of area affected
• requires radioactivity
• either excercise or pharmacological stress: adenosine, dipyridamole, dobutamine

Question 18

Investigations of stable angina - cardiac catheterisation/coronary angiography

Answer 18

• shows, sites, distribution and nature of atheromatous disease
• allows decision on what treatment is best
• whether medication alone/percutaneous coronary intervention and stengting or coronary artery bypass graft surgery
• done under local anaesthetic
• arterial cannula inserted into femoral/radial artery
• coronary catherters passed to aortic root + itnroduced into ostrium of coronary arteries
• radio-opaque contrast injected down coronary arteries and visualised on x-ray

Question 19

What is an invasive coronary angiography?

Answer 19

a 2D ‘lumenogram’’ as iodinated contrast/dye is passed through arteries

Question 20

Atheroma in an invasive coronary angiography

Answer 20

views in different planes as atheroma is eccentric in natture
-?? shows stenosis in mid right coronary artery, amendable to angioplasty

Question 21

Treatment strategies for treatment for stable angina

Answer 21

General
-address risk factors ( BP,c holesterol, DM, lifestyle)

Medical treatment

Revascularisation ( if symptoms not controlled)
-percutaneous coronary intervention + coronary artery bypass grafting

Question 22

Treatment of stable angina

Answer 22

Influencing disease progression:

• Statins
• ACE inhibitors
• aspirin

For relief of symptoms:

• Beta blockers
• Ca2+ channel blockers
• Ik channel blockers
• Nitrates
• K+ channel blockers

Question 23

Treatment of stable angina- Statins

Answer 23

• consider if total cholesterol > 3.5mmol/L

- Reduces LDL-cholesterol depositiation in atheroa and stabilises atheroma reducing plaque rupture and ACS?

Question 24

Treatment of stable angina- ACE inhibitors

Answer 24

• if increased CV risk + atheroma

- stabilises endothelium + reduces plaque rupture

Question 25

Treatment of stable angina: Apsirin

Answer 25

- 75mg/clopidogrel if intolerant to aspirin | - may not directly affect plaque but protects endothelium + prevents platelet activation/aggregation

Question 26

Treatment of stable angina - beta blockers

Answer 26

- achieve resting HR < 60bpm | - reduced myocardial work + antiarrythmic effects

Question 27

Treatment of stable angina - Ca2+ channel blockers

Answer 27

- achieve resting HR < 60bpm - central acting ( diltiazem/verapamil if Beta blockers C-I - produce vasodilation; peripherally acting dihydropyridines ( amlogipine, feldodipine)

Question 28

Treatment of stable angina- Ik channel blockers

Answer 28

- achieve resting HR < 60bpm | - ivabridine reduces sinus node rate

Question 29

Treatment of stable angina - K+ channel blockers

Answer 29

- nicorandil | - nitrate molecule + K+ channel helpful in preconditioning?

Question 30

Treatment of stable angina - percutaneous coronary intervention

Answer 30

- similar beginnings to coronary angiography but cross stenotic lesion with guidewire and squash athermoatous plaque into walls with ballone and stent - if stent used, aspirin and clopidogrel taken together whilst endothelium covers stent struts and is no longer seen as a foreign body with associated risk of thrombosis

Question 31

Risks of PCI

Answer 31

-RETONOSIS

Question 32

Risks of PCI

Answer 32

-Retonosis

Question 33

Treatment of stable angina - coronary artery bypass surgery

Answer 33

- in diffuse multi vessel CABG best option for stable angina | - patients must continue disease modifying medication and predicatble detiorartion in vein grafts after 10yrs