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Cardiovascular System > Chronic Chest Pain > Flashcards

Flashcards in Chronic Chest Pain Deck (21):
1

Chronic Angina is?

Symptom caused by fixed coronary stenosis in the arteries from atherosclerosis of coronary arteries.

2

Patients symptoms at rest vs patients symptoms during physical activity

Rest: Blood supply to heart sufficient, patient is symptom free.

Physical activity: as Cardiac work and demand increases, partially occluded coronary vessel prevents this demand from being meet > ischaemic cardiac muscle and chest pain.

Back to rest: rebalance of flow, blood goes away

3

Is treating chronic angina a medical emergency

No, it is more of a long-standing issue that can be treated. The issue is getting the patient to take their treatment

4

Classical signs of angina

Age
Hypertension
smoke
diabetes
previous heart issues
Nausea, sweating
Pain/tightness/heaviness during movement, eases at rest.
Does the pain go to neck/L arm?

5

Investigations you can do to diagnose

-Exercise-test with ECG to show ischaemia as HR inc
-Exercise echo
-CT scan of coronary arteries
-angiograms

6

Examination you can do to diagnose angina

-Bp
-Weight
-Murmurs (stenosis)

7

Angina Management

Pharmacological: reduce symptoms and/or CVS risk

Interventional: surgery, stent

8

Pharmacological Treatments that reduce symptoms

-Beta-blockers (decrease energy and cardiac work)
-Nitrates (VD)
-Calcium channel blockers (VD)

9

Pharmacological Treatments that reduce CVS risk

-Anti-platelets (aspirin)
-Lipid Lowering (statins)

More about long term outcome

10

Typical drug list for a patient with chronic angina

1) Beta-blocker; metoprolol
2) Calcium channel blocker
3) isosorbide mononitrate
4) GTN spray 'as required'
5) aspirin
6) statin

This is an issue, as patient compliance is low due to a quite hefty list of drugs they are required to take daily.

11

Drug management

-initiate drug
-Titrate dose (start w low dose)
-Review patient; symptoms resolution, side effects

Long term followup required

12

Beta-blockers

-Reduce cardiac work: decrease HR and c.work (aim HR: 60-70bpm)
decrease ischaemic burden

-Reduce BP
-Improve prognosis
-FIRST LINE THERAPY to reduce angina symptoms

13

Calcium Channel Blockers

-Block voltage-operated L-type Ca channels; in cardiac and SM
Vascular smooth muscle: decreases arterial SM tone, vascular peripheral resistance, BP

Cardiac cells: decrease contractility, sinus node rate and AV node transmission


-Some selectivity between tissues

14

Calcium channel blockers for resistance vessels

Dihydropyridine

- ) flushing, headache, oedema

15

Calcium channel blockers for cardiac tissue

Phenylalkylamine

- )Heart block, negative inotrope, constipation

16

Nitrates

-Vasodilators, can be used everyday (chronic) or for acute required use (can be done because they are so lipophilic! straight into circulation!)

17

Nicorandil

1) Nitrate-like effect
2) K+ ATP channel opener: hyperpolarises cell and inactivates VC

-symptom relief
- Predictable side effects (headaches)

18

Lipid-lowering drugs: Statins

Primary and secondary prevention

Primary Prevention: treat if 10 year CVS >30%

Secondary Prevention: coronary artery disease (angina)**********, cerebrovascular disease, peripheral vascular disease

19

Frequently used statins in NZ

simvastatin

atorvastatin
Heaps of evidence of effect.
there are some others that are less frequently used due to being less effective

20

Statins: mechanism of action

Synthasizing cholesterol (in hepatocytes) is v important. Acetyl CoA to cholesterol

Statins inhibit enzyme 'HMG CoA reductase', stoping the step in the pathway

HMG Coa --X---> Mevalonate

Hepatocytes, respond to this by expressing lots of LDL receptors, effectively 'mopping' up the circulating LDL to make/use sufficient cholesterol

LDL levels lower

21

Concern with using statins

lots of potentially drug interactions: simvastatins is metabolised by cytochrome P450

Side Effects:
-Myalgias (aches and pains), reduce dose?
-Myositis; stop if CK x10
-Rhabdomyolysis; overwhelming inflamm/destruction, releases myoglobin
-Deranged LFTs; stop if ALT x3

Teratogenic: shouldn't be given in pregnancy