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ACC > Angina and ACS > Flashcards

Angina and ACS Flashcards

1
Q

3 Features of Angina

A
  1. Chest pain radiating to jaw, neck, shoulders or arms
  2. Symptoms brought on by exertion
  3. Symptoms relieved by 5mins rest or GTN spray
    All 3= Typical
    2= Atypical
    0-1= Non-Anginal
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2
Q

Precipitants of angina

A

Emotions, cold weather, heavy meals

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3
Q

Associated symptoms of angina

A

Dyspnoea, nausea, sweatiness, faintness

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4
Q

Features that make angina less likely

A

Pain that is continuous, pleuritic or worse with swallowing.

Pain associated with palpitations, dizziness or tingling

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5
Q

Causes of angina

A

Atheroma

Rarely: anaemia, coronary artery spasm, AS, tachyarrythmias, HCM, arteritis

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6
Q

Types of angina

A

Stable- induced by effort, relieved by rest. Good prognosis
Unstable (crescendo)- Increases in frequency or severity, occurs on minimal exertion or at rest; associated with increased risk of MI
Decubitus angina- precipitated by lying flat
Variant (Prinzmental)- caused by coronary artery spasm

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7
Q

Angina Ix

A

ECG- normal may show ST depression, flat or inverted T waves, signs of past MI
Bloods- FBC, U/E, TFTs, lipids, HbA1c- reasons? see PUK
Consider echo and CXR

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8
Q

ECG in angina

A

Normal does not rule out angina, may show signs of ischaemic changes
Changes on resting ECG consistent with CAD include
-Pathological Q waves
-Left bundle branch block
-St-segment and T wave abnormalities

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9
Q

Angina epidemiology
More common F/M?
Ethnicities?

A

More common in South Asian population
Black Afro-Caribbean people have reduced risk
Higher in lower socio-economic groups

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10
Q

Angina risk factors

A

Increasing age, male gender, CV RF, smoking, diabetes, hypertension, dyslipidaemia, FH of premature CAD, Hx of CAD

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11
Q

Angina Differentials

A

MI- longer than 5mins not relieved by rest
Prinzmetal’s- occurs at rest and exhibits circadian pattern, most episodes occurring early in morning
Acute pericarditis- constant, aggravated by inspiration, lying flat, swallowing and movement
MSK pain- worse on movement
Reflux
Pleuritic
Dissection
Gallstones

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12
Q

If estimated likelihood of CAD greater than 90%?

A

Further investigation unnecessary, manage as angina

Arrange blood tests for conditions that exacerbate angina

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13
Q

Symptoms suggesting ACS

A

Pain at rest (may occur at night)
Pain on minimal exertion
Angina that seems to be progressing repidly
- refer urgently

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14
Q

Ix confirmed CAD in context of angina

A

Treat as stable angina

If suspected that pain is not caused by ischaemia, offer non-invasive functional imaging or refer for exercise testing

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15
Q

If likelihood of CAD between 10-90%?

A

Arrange bloods for conditions that exacerbate angina

Consider aspirin if likely to be stable angina

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16
Q

If estimated likelihood of CAD is 61-90%?

A

Offer invasive coronary angiography

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17
Q

If estimated likelihood of CAD is 30-60%?

A

Offer non-invasive functional imaging for myocardial ischaemia
-MPS, stress echo, first pass contrast enhanced MR perfusion

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18
Q

If estimated likelihood of CAD is 10-29%

A

Offer CT calcium scoring

19
Q

If estimated likelihood of CAD is less than 10%

A

Consider other causes

20
Q

Pharmacological management of angina

A
  • GTN symptom relief
  • Aspirin (clopidogrel if contra)
  • Statins
  • Beta blocker or CCD
  • Then switch or combine
  • If one contra-indicated add a long acting nitrate, ivabradine or ranolazine
  • If both contra-indicated monotherapy with long acting nitrate, ivabradine or ranolazine
  • ACEi if diabetic
21
Q

Coronary revascularisation

A

For those at high risk and those who have failure to be controlled

22
Q

Patients who do not respond to treatment

A
  • Explore patients understanding
  • Establish how symptoms affect quality of life
  • Review diagnosis and consider other causes
  • Explain how the patient can self manage
  • Explain role of psychological factors in pain
23
Q

Angina advice to patient

A

Reduce CV RFs (smoking, diet, physical activity, alcohol)

24
Q

Sexual activity for angina?

A

If patient can climb up and down two flights of stairs briskly without symptoms, sexual activity unlikely to precipitate episode of angina

25
Q

If sexual activity does precipitate angina?

A

GTN spray immediately before intercourse

26
Q

Contraindication to GTN spray?

A

Phosphodiesterase inhibitors

27
Q

Complications of angina

A
  • Cardiovascular complications
  • Anxiety and depression
  • Reduced general health
28
Q

Prognosis

A

Annual mortality 1.2-2.4%

29
Q

ACS RF

A
  • NM for atherosclerosis: age, male, FH, premature menopause

- M for atherosclerosis: smoking, DM, hypertension, dyslipidaemia, obesity, inactivity

30
Q

ACS Presentation

A
  • STEMI and NSTEMI may be indistinguishable
  • Prolonged anginal pain at rest
  • New onset angina limiting daily activities
  • Recent destabilisation of angina
  • Post MI angina
31
Q

ACS chest pain

A

Associated with sweating, nausea, vomiting, fatigue, SoB, palpitations
-Some patients (particularly elderly and diabetics) may not have chest pain

32
Q

Should response to GTN be used to diagnose ACS

A

No

33
Q

ACS Differentials

A
  • CV: acute pericarditis, myocarditis, aortic stenosis , aortic dissection, PE
  • Resp: pneumonia, pneumothorax
  • GI: oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis
  • MSK
34
Q

ACS Ix

A
  • ECG
  • Cardiac Enzymes
  • FBC
  • Blood glucose (hyperglycaemia common and powerful predictor)
  • Echo
  • CXR (alternative diagnoses)
  • Cardiac MRI
  • Coronary angiography gold standard
35
Q

Within first six hours which is superior for detection of MI?
Troponins or CK-MB?

A

Troponins

36
Q

Timeline of troponin

A

Detectable 3-6 hours after infarction, peak at 12-24 hours, remains raised for 14 days

37
Q

Test troponins when

A

Between 6-12 hours after onset of pain

38
Q

For ACS, after aspirin and antithrombin therapy have been offered, do what?

A

Risk assessment, GRACE score

39
Q

Management of NSTEMI/unstable angina

A
  • Oxygen
  • Nitrates: if sublingual ineffective; IV or buccal
  • If pain continues morphine
  • Aspirin 300mg
  • If high risk (GRACE, secondary criteria, rise in troponin)
  • LMWH
  • IV nitrate
  • Beta blockers
  • If high risk: Glycoprotein IIb/IIa inhibitors
40
Q

Management of STEMI

A

-Oxygen
-Morphine
-Aspirin+ticagrelor
-PCI or thrombolytic drug
-If PCI not available within 90mins, thrombolytic drug with any heparin
-Nitrates; if ineffective, IV
-Beta blockers
-ACE inhibitors
Monitor hyperglycaemia

41
Q

Long-term management of STEMI

A

Discharge with

  • Aspirin
  • Clopidogrel (if intolerant prasugrel or ticagrelor, or warfarin if low risk of bleeding)
  • Beta blockers
  • ACEi
  • Nitrates
  • Statins
42
Q

Which troponins are most specific to the heart?

A

I and T

43
Q

Causes of raised troponin

A

MI, Right ventricular strain (from massive PE), sepsis, renal failure, burns SAH
-change in troponin level is often more important than actual troponin level

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