Ischemic Heart Disease: Stable angina (Complete)

Question 1

Define ischaemic heart disease

Answer 1

Condition characterised by inability to supply adequate oxygen to the myocardium

Question 2

What is the primary aetioligical cause of ischaemic heart disease?

Answer 2

Atherosclerosis of coronary arteries

Question 3

Ischaemic heart disease is interchangable with which other terms? (3)

Answer 3

Coronary artery disease

Coronary heart disease

Chronic coronary syndrome

Question 4

What are the two main types of ischaemic heart disease?

Answer 4

Stable ischaemic heart disease

Acute coronary syndrome

Question 5

List 4 examples of types of stable ischaemic heart disease.

Answer 5

Stable angina pectoris

Vasospastic angina (Prinzmetal variant angina).

Microvascular angina (cardiac syndrome X).

Angina associated with myocardial bridging of coronary arteries (arteries enter the myocardium vs lying on its surface)

Question 6

List 3 examples of acute coronary syndromes

Answer 6

Unstable angina

STEMI

Non-STEMI

Question 7

List the 8 main risk factors for stable angina

Answer 7

Old age

Smoking

Hyperlipidaemia

Hypertension

DM

Male sex (females risk rapidly increases post menopause)

Obesity

Illicit drug use (e.g. cocaine, methamphetamine) increases myocardial oxygen demand and can promote vasospasms.

Question 8

Strongest risk factor for ischaemic heart disease is?

Answer 8

Old age

Question 9

What are the 3 main characteristics of stable angina?

Answer 9

Substernal chest discomfort (pressure or squeezing) that lastsfor several minutes

Provoked by exercise or emotional stress

Relieved with rest or glyceryl trinitrate

Question 10

What are atypical angina symptoms?

Answer 10

Patients tend to only experience two of the three main characteristics of angina:

Chest pain (squeezing, pressure) lasting minutes.

Induced by exercise or emotional stress

Relieved with rest or glyceryl trinirate

Question 11

What groups of patients are more likely to present with atypical angina? (3)

Answer 11

Women

Diabetics

Older people

Question 12

What physical examination findings are indicative of stable angina?

Answer 12

Normal examination findings (e.g. cardiovascular exam is fine)

Question 13

List 4 1st order investgations to perform in patients suspected of stable angina

Answer 13

Bedside
Rapid ECG

Bloods:
FBC: Check for anaemia which can worsen IHD
HbA1c (to identify diabetes which is a strong risk factor)
Lipid profile: Cardiovascular risk factor
TFTs: Exclude hyperthyroidism
U&Es: Establish baseline kidney function

Imaging:
CTA: Diagnostic for stable angina. (Contraindicted in patients with renal impairment)
Myocardial perfusion SPECT: If CTA contraindicted
Stress ECHO: If CTA contraindicted

Question 14

What 3 ECG findings may be indicative of stable angina?

Answer 14

Normal ECG findings

ST changes: E.g. ST deppresion on V5 and V6

Q-waves: Suggests a previous MI

Question 15

What is the 1st line management plan for stable angina?

Answer 15

Supportive:

Lifestyle education
* Weight management
* Exercise
* Dietary changes
* Smoking cessation.

Medication:

Antiplatelet therapy: Aspirin, clopidogrel

Statin

Beta-blocker or calcium channel blocker (dihydropyridine CCB such as amlodipine, felodipine, nifedipine)

Sublingual GTN spray (glyceryl trinitrate)

Question 16

What is the purpose of antiplatelet therapy for treatment of stable angina?

Answer 16

To provide secondary prevention against heart attacks or strokes

Question 17

What is the purpose of sublingual glyceryl trinitrate for treatment of stable angina?

Answer 17

Helps to relieve acute episodes and can be prophylactic and used before episodes of exertion (e.g. exercise)

Question 18

List complications that can arise in patients with stable angina. (5)

Answer 18

Ischaemic heart failure/cardiomyopathy

Myocardial infarction

Stroke

Sudden cardiac death or arrest (Due to arrythmia due to scar tissue formation or due to acute ischamia or infarction)

Peripheral artery disease (Both cause by atherosclerotic changes so treatment of stable IHD can also treat and reduce risk of PAD)

Question 19

What other condition can be treated with glyceryl trinitrate and can often be misdiagnosed as angina?

Answer 19

Oesophageal spasms

Question 20

What surgical interventions can be considered in some patients with stable angina?

Answer 20

CABG

PCI

Question 21

What are the indications for surgical intervention of stable angina?

Answer 21

Patient must me on optimal medication, symptomatic AND any of following:

Complex 3 vessel disease

Significant left main stem stenosis