Ischemic Heart Disease: Unstable angina (Complete)

Question 1

Define unstable angina

Answer 1

Myocardial ischaemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis.

Question 2

What are typical ECG findings in patients with unstable angina in comparison to MI? (5)

Answer 2

No evidence of ST-elevation MI

ECG may be normal

ECG may show transient ST-elevation

ECG may show ST-deppresion

ECG may show T-wave inversion

N.B. The ECG must not show changes from previous ECG readings. If it does, points towards other causes

Question 3

How does unstable angina compare to MI in terms of troponin findings?

Answer 3

Unstable angina shows no cardiac troponin elevation (indicating no cardiomyocyte injury or necrosis).

MI would show elevated levels

Question 4

What is the most common underlying cause of acute myocardial ischaemia (e.g. unstable angina)?

Answer 4

Coronary artery disease

Question 5

A less common/rare cause of acute myocardial ischaemia characterised by intense vasospasms of the coronary arteries is known as?

Answer 5

Varient angina or Prinzmetal’s angina

Question 6

MI can also display a normal or non ST-elevated ECG. This subtype of MI is known as?

Answer 6

NSTEMI (Non-ST elevation myocardial infarction)

Question 7

How can a NSTEMI and unstable angina be differentiated?

Answer 7

NSTEMI would show elevated troponin levels whereas unstable angina would show no elevation.

Question 8

An acute coronary syndrome (e.g. unstable angina, MI) should always be suspected in patients presenting with which key features? (4)

Answer 8

Must have presented with acute chest pain which includes pain in other areas (e.g. neck, jaw, arm) and any of these features:

Pain has lasted more than 15 minutes

Associated symptoms including: Nausea, vomitting, sweating, breathlessness

New in onset or occurs in patient with known history of stable angina

Question 9

How is unstable angina chest pain typically described as being?

Answer 9

Pressure

Tightness

Burning

Question 10

What are some atypical presentations of unstable angina that should be considered? (5)

Answer 10

Epigastric pain

Indigestion

Isolated dyspnoea

Isolated syncope

Back pain (Middle/Upper) [Typical in woman]

Question 11

Atypical presentations of unstable angina chest pain is most common in which groups of patients? (4)

Answer 11

Woman

Diabetes

Chronic kidney disease

Dementia

Question 12

What 8 investigations should always be ordered in patients suspected of having an acute coronary syndrome?

Answer 12

_Bedside_:

ECG

Basic obs: Haemodynamic status

Bloods:

FBC (check for anaemia and estimate risk of bleeding)

CRP (check for infective cause of aute chest pain such as pneumonia)

U&Es (determine choice of anticoagulant)

LFTs (assess bleeding risk)

Troponin

Glucose

Imaging:

CXR: Rule out other causes (e.g. pneumothorax, aortic dissection_

Question 13

What essential questions must be asked when taking the history of patients presenting with acute chest pain? (4)

Answer 13

Is the patient experiencing the chest pain now and if not when was the last episode? (helps to determine timing of high troponin sensitivity).

History and character of chest pain including: Have they experienced this type of pain before?
SOCRATES.

Check for risk factors

Previous investigations for chest pain

Question 14

List some risk factors for unstable angina (12)

Answer 14

Diabetes

Hyperlipidaemia

Hypertension

Metabolic syndrome

Renal impairment

Peripheral arterial disease

A history of ischaemic heart disease and any previous treatment

Obesity

Advanced age

Smoking

Cocaine use

Physical inactivity

Question 15

List some risk factors for unstable angina (12)

Answer 15

Diabetes

Hyperlipidaemia

Hypertension

Metabolic syndrome

Renal impairment

Peripheral arterial disease

A history of ischaemic heart disease and any previous treatment

Obesity

Advanced age

Smoking

Cocaine use

Physical inactivity

Question 16

What 3 medications should be checked for before administering treatment to patients suspected of unstable angina?

Answer 16

Anticoagulants

Antiplatelet drugs

Recent use of phosphodiesterase inhibitors (sildenafil, vardenafil, or tadalafil) [Used in COPD, BPH, erectile dysfunction)

Question 17

What allergies should be checked for in patients suspected of having unstable angina before treating them?

Answer 17

Check for hypersensitivity to aspirin

Question 18

What are typicial presentations that can be found on physical examination of patients suspected of unstable angina?

Answer 18

Physical examinations may be normal however some patients may have significant sweating

Question 19

What findings on physical examination are very atypical in patients with unstable angina and should instead drive suspicion more towards an acute MI? (3)

Answer 19

Low blood pressure

Evidence of left ventricular failure

Life threatnening arrythmias (e.g. ventricular tacchycardia or fibrilation)

Question 20

What is a typical presentation of chest pain caused by unstable angina?

Answer 20

Pain is retrosternal

Described as pressure, tightness or burning

Radiating to the left arm, both arms, right arm, neck, or jaw.

Pain can be consistent or intermittent

Question 21

List examples of differentials to consider in patients with unstable angina (8)

Answer 21

Stable angina

Myocardial infarction (STEMI and non-STEMI)

Congestive heart failure

Aortic dissection

Pericarditis

Myocarditis

Pulmonary embolism

Chest wall pain

Pneumothorax

Perforated abdominal viscus

Question 22

How does the presentation of stable angina differ to unstable angina? (3)

Answer 22

Pain occurs only in context of exertion or emotional stress

Pain is not worsened over time

Pain is relieved by nitrates or rest

Question 23

How does the presentation of MI differ to unstable angina?

Answer 23

Clinical presentations may be indistinguishable so must be ruled out via investigations (e.g. CXR, troponin)

Question 24

How does the presentation of congestive heart failure differ to unstable angina? (2)

Answer 24

Presents more predominantly with SoB, Dysponoea, Orthopnea.

Chest pain my occur if coronary perfusion is poor

Question 25

How does the presentation of chest wall pain differ to unstable angina? (3)

Answer 25

Pain replicated on movement or palpation. Pain not relieved by rest or nitrates but may be relieved by local injection of lidocaine

Question 26

How does the presentation of pericarditis differ to unstable angina? (4)

Answer 26

Pain relieved when sitting up and leaning forward. Pain worsened when supine Pericardial rub may be heard Have history of recent myocardial infarction, renal failure, chest irradiation, or associated connective tissue disease.

Question 27

How does the presentation of myocarditis differ to unstable angina?

Answer 27

May have had a recent viral infection Chest pain is sometimes pleuritic More likely to present with signs of heart failure (e.g. peripheral oedema, dyspnoea), palpitations or fatigue

Question 28

How does the presentation of aortic dissection differ to unstable angina? (3)

Answer 28

Chest pain is often tearing and radiates to the back between the shoulder blades May have a medical history of hypertension, Marfan's or Ehler's Danlos syndrome. May have radio-radial delay, diastolic murmur or aortic regurgitation

Question 29

How does the presentation of a pulmonary embolism differ to unstable angina? (3)

Answer 29

Present with acute presentations of SoB, pleuritic chest pain or syncope. May present with hypoxia, cyanosis, elevated jugular venous pressure with hypotension, and clear lung fields. May have a history of: Recent surgery, immbolisation, air travel, cancer

Question 30

How does the presentation of a pneumothorax differ to unstable angina? (3)

Answer 30

Acute chest pain with shortness of breath May have tracheal deviation, hyperesonance of decreased breath sounds. Underlying lung disease, trauma, or recent procedures (such as insertion of central venous line).

Question 31

How does the presentation of a perforated abdominal viscus (aka bowel peforation) differ to unstable angina? (3)

Answer 31

Typically presents with abdominal pain. Chest pain is referred but may be mistaken for cardiac origin. Abdominal examination shows localised tenderness and, in cases of peritonitis, generalised tenderness. History of previous peptic ulcer disease, diverticulitis, or recent bowel biopsy. N.B. CXR also shows gas bubble under diaphragm

Question 32

What is the initial management plan for patients presenting with unstable angina? (5)

Answer 32

1) Oxygen (if sats are <90) 2)**300mg Aspirin + Fondaprinux (antithrombin)** (Check for allergies or significant bleeding risk) 3) **Calculate GRACE** (6-month mortality predictor) 4) Translingual/sublingual glyceryl trinitrate (pain relief) **For low risk mortality**: Low bleeding risk: Aspirin + ticagrelor High-bleeding risk: Aspririn + clopidogrel (P2Y12 inhibitor) **For intermediate/high risk mortality**: Haemodynamically unstable: Immediate angioplasty Haemodynamically stable: ticagrelor + aspirin with follow-up angioplasty within 72 hours Replace tricagrelor with prasugrel if undergoing a PCI (angioplasty with stenting)

Question 33

Name the antithrombin initially administered to patients with unstable angina

Answer 33

Fondaprinux

Question 34

Name the painkiller administered to patients with unstable angina

Answer 34

glyceryl trinitrate

Question 35

List 2 examples of types of P2Y12 inhibitors

Answer 35

Clopidogrel Prasugrel ## Footnote Prasugrel has higher bleeding risk than clopidogrel

Question 36

What is the long term management plan for patients with unstable angina?

Answer 36

**_Supportive_**: Cardiovascular risk factor modification (e.g. lifestyle/diabetes/lipids) **_Medical_**: Beta-blocker (e.g. bisoprolol) or CCB (e.g. verapamil). Discuss cardiovascular disease risk factor modification ## Footnote Increase dosages of the medications if patient already taking them

Question 37

How can a patient's risk of bleeding be assesed before adminsitering aspirin or anticoagulants (e.g. fondaprinux)?

Answer 37

HAS-BLED score

Question 38

Administraton of aspirin and fondaprinux/PY2Y12 inhibitor in patients suspected of unstable angina is known as?

Answer 38

Dual anti-platelet therapy

Question 39

What tool can be used to predict prognosis for patients with acute coronary syndrome?

Answer 39

GRACE score

Question 40

What is considered low risk and intermediate/high risk based on GRACE scores?

Answer 40

Low risk is 6 month mortality less than or 3% Intermediate/High risk is 6 month mortality greater than 3%

Question 41

What are 2 complications that can occur when treating patients with unstable angina?

Answer 41

Bleeding Thrombocytopenia

Question 42

What are 2 complications that can arise in patients with unstable angina?

Answer 42

Congestive heart failure (Chronic ongoing ischaemia can cause myocardial damage overtime) Ventricular arrythmias (tacchycardia and fibrilations)