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Systems 2: Cardiovascular > SIHD and Angina > Flashcards

SIHD and Angina Flashcards

1
Q

What is the definition of angina?

A

Cardiac chest pain

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2
Q

What is the pathophysiology of myocardial ischaemia and angina?

A
  • Mismatch between supply of O2 and metabolites to myocardium and the myocardial demand for them
  • Most commonly due to reduction of coronary blood flow
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3
Q

What ways are the coronary arteries blocked?

A
  • Obstructive coronary atheroma
  • Coronary artery spasm (dynamic obstruction)
  • Coronary inflammation/arteritis
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4
Q

What other ways can O2 be reduced to the myocardium?

A
  • Anaemia
  • LVH (from persistent hypertension, aortic stenosis or hypertonic cardiomyopathy)
  • Thyrotoxicosis
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5
Q

When would angina be most prominent if it is due to a lack of O2 to the myocardium?

A
  • During activity the HR and BP rise putting strain on the heart
  • Anxiety/emotional stress
  • Can cause angina
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6
Q

What is “stable angina”?

A

Symptoms only on activity

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7
Q

What is the typical distribution of precordial pain?

A
  • (retrosternal)
  • Left chest
  • Left arm
  • Neck on occasion
  • Abdomen in women
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8
Q

What is the character of angina?

A
  • Often described as a “tight band” on the chest or heaviness
  • Can radiate to mandible as well
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9
Q

What relieving factors are there for angina?

A
  • GTN (rapid relief)

- Physical rest

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10
Q

What type of pain is typically not angina?

A
  • Sharp stabbing pain
  • Associated with movement
  • Localised pinpoint site
  • Superficial
  • No pattern
  • Begins AFTER exercise
  • Long lasting
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11
Q

What might a sharp stabbing pain be?

A
  • Pleuritic or pericardial
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12
Q

What is the differential diagnoses for chest pain?

A
  • Cardiovascular causes
  • Respiratory
  • Musculoskeletal
  • GI
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13
Q

What are the other cardiovascular causes of pain used in the differential?

A
  • Aortic dissection

- Pericarditis

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14
Q

What are the respiratory causes for chest pain used in the differential?

A
  • Pneumonia
  • Pleurisy
  • Peripheral PE
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15
Q

What are the musculoskeletal causes for chest pain used in the differential?

A
  • Cervical disease
  • Costochondritis
  • Muscle spasm/strain
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16
Q

What are the GI causes for chest pain used in the differential?

A
  • GORD
  • Oesophageal spasm
  • Peptic ulceration
  • Biliary colic
  • Chocystitis
  • Pancreatitis
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17
Q

What symptoms ON EXERTION are in the history with myocardial ischaemia?

A
  • Breathlessness
  • Excessive fatigue
  • Near syncope
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18
Q

What are the non modifiable risk factors for coronary artery disease?

A
  • Age
  • Gender
  • Creed
  • Family history and genetic factors
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19
Q

What are the modifiable risk factors for coronary artery disease?

A
  • Smoking
  • Lifestyle - diet and exercise
  • Diabetes mellitus
  • Hypertension (reducing BP reduces CV risk)
  • Hyperlipidaemia (lowering reduces CV risk)
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20
Q

How is diabetes a modifiable risk factor?

A

Good glycaemic control reduces CV risk

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21
Q

What are the factors on examination, along with angina, that point towards CV

A
  • Tar stains on fingers
  • Obesity
  • Xanthalasma
  • Corneal arcus (both show hypercholesteraemia)
  • Hypertension
  • Abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses
  • Diabetic retinopathy
  • Hypertensive retinopathy on fundoscopy
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22
Q

What signs of exacerbating or associated conditions exist with angina?

A
  • Pallor or anaemia
  • Tachycardia
  • Tremor
  • Hyper-reflexia of hyperthyroidism
  • Ejection systolic murmur
  • Plateau pulse of aortic stenosis
  • Pansystolic murmur of mitral regurgitation
  • Basal crackles, elevated JVP, peripheral oedema
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23
Q

What are the first investigations done on admission of stable angina?

A
  • FBC
  • Lipid profile and fasting glucose
  • CXR (can rule out other causes)
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24
Q

What would be the next and most important step in the diagnosis?

A
  • Electrocardiogram
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25
Q

What will an electrocardiogram be able to show evidence of?

A
  • Past MI

- Left ventricular hypertrophy

26
Q

What will show a past MI on an electrocardiogram?

A
  • Pathological Q waves
27
Q

What will show left ventricular hypertrophy on an electrocardiogram?

A
  • High voltages

- Lateral ST segment depression or “strain pattern”

28
Q

What is an ETT?

A

Exercise tolerance test

29
Q

What does an exercise tolerance test allow?

A
  • CV to be under stress

- Will show ST segment depression for positive test

30
Q

What does a negative ETT NOT rule out?

A
  • Coronary atheroma

- Negative at high workload means overall good prognosis

31
Q

What is better than ETT in detection of coronary vascular disease, localisation of ischaemia and size of affected area?

A
  • Myocardial perfusion imaging
32
Q

What is bad about myocardial perfusion imaging?

A
  • Expensive
  • Involves radioactivity
  • Sometimes unavailable
33
Q

What is the process of myocardial perfusion imaging?

A
  • Radionuclide tracer injected at peak stress and images taken
  • Stress images compared to rest images
34
Q

What will happen to the radionuclide tracer around healthy normal myocardium?

A

Will be absorbed

35
Q

If the tracer is seen at rest but not after stress what is the diagnosis?

A

Ischaemia

36
Q

If the tracer isn’t seen at rest or after stress what is the diagnosis?

A

Infarction

37
Q

What other imaging techniques can be used to asses the coronary arteries?

A
  • CTCA (coronary artery angiography)
38
Q

When should invasive angiography be done during investigation?

A
  • Early or strongly positive ETT
  • Angina refractory to medical therapy
  • Diagnosis unclear
  • Young cardiac patients
  • Occupation with risk (drivers)
39
Q

What types of invasive angiography are there?

A
  • Cardiac catheterisation

- Coronary angiography

40
Q

What do the invasive angiographies allow?

A
  • The extent of atheromatous disease and what treatment is best
  • Whether medication alone or percutaneous coronary intervention is needed
41
Q

What are the two types or percutaneous coronary intervention (PCI) are there?

A
  • Angioplasty and stenting

- Coronary artery bypass graft (CABG)

42
Q

What arteries are the arterial cannulas usually inserted into?

A
  • Femoral or

- Radial

43
Q

What is the path of the coronary catheters?

A
  • Into the aortic root

- Introduced into ostium of coronary arteries where it enters

44
Q

How are the images from cardiac catheterisation done?

A
  • Radio opaque contrast injected down coronary arteries
45
Q

What are the general measures taken in addressing the risk factors after a diagnosis is made?

A
  • Control BP if high
  • Control diabetes mellitus if hyperglycaemic
  • Reduce cholesterol
  • Alter lifestyle
46
Q

What drugs can a stable angina sufferer be put on to reduce disease progression?

A
  • Statins to reduce LDL cholesterol deposition
  • ACE-I if increased CV risk
  • Low dose aspirin (or clopidogrel if intolerant)
47
Q

What drugs can be used to relieve angina symptoms?

A
  • B blockers (anti arrhythmic)
  • Ca2+ channel blockers
  • Ik channel blockers

All to reduce HR

48
Q

What is examples of Ca2+ channel blockers are used commonly?

A
  • Diltiazem

- Verapamil

49
Q

What is a new Ik channel blocker medication that reduces sinus node rate?

A
  • Ivabridine
50
Q

What else can calcium channel blockers do?

A
  • Produce vasodilation
51
Q

What Ca2+ channels cause vasodilation?

A
  • Amlodipine

- Felodipine

52
Q

What are nitrates used for with angina?

A
  • Produce vasodilation
53
Q

What types of nitrates are administered for angina?

A
  • Sublingual buccal spray (GTN)

- Prolonged/short acting tablets

54
Q

At what point is revascularisation considered?

A

When two anti anginals are used and no respite is gained

55
Q

What types of PCI are there?

A
  • Percutaneous transluminal coronary angioplasty

- Stenting

56
Q

What is the process of PCI?

A
  • Similar start to coronary angiography
  • Cross stenotic lesion with guidewire inserted
  • Atheroma plaque squashed into walls with a balloon and then stented
57
Q

What drug treatment is taken following stenting?

A
  • Aspirin and clopidogrel taken whilst endothelium covers the stent
58
Q

Why does the endothelium need to cover the stent?

A
  • Can be seen as foreign body

- Risk of thrombosis

59
Q

What are the negatives of PCI?

A
  • No evidence of prognosis improvement
  • Small risk of procedural complication (0.1% death)
  • Risk of restenosis with bare metal stents and drug eluding stents
60
Q

What is the benefit of coronary artery bypass surgery (CABG)?

A
  • 80% symptom free 5 years after op

- Prognostic benefit in some groups

61
Q

Negative of CABG?

A
  • High op risk

Systems 2: Cardiovascular (19 decks)

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