Flashcards in Stable Angina Deck (28):
What is stable angina and how does it differ from unstable angina?
pattern of exercise and/or stress-related angina that is transient, relieved with rest or nitro and does not result in myocardial damage (unlike ACS/unstable angina)
What causes angina?
imbalance between myocardial oxygen supply and demand
What factors determine myocardial oxygen demand?
myocardial wall stress
What factors determine myocardial oxygen supply?
oxygen carrying capacity (Hgb and sat)
coronary artery blood flow
coronary artery perfusion pressure (=diastolic bp)
What is the relationship between resistance, length of the vessel, viscosity, and radius of the vessel?
R is proportional to length and viscosity and inversely proportional to the radius (^4)
Typical angina requires what three features?
1) substernal chest discomfort with characteristic quality and duration that is
2) provoked by exertion or stress and relieved
3) by rest or nitro
atypical angina; 2/3
noncardiac chest pain: 0-1/3
What is grading scale for stable angina?
Class I - angina only with strenuous/rapid/prolonged activity
Class II - only slight limitation of ordinary activity
Class III - marked limitation of ordinary physical activity
Class IV - inability to carry out any physical activity - angina may be present at rest
What is the quality of stable angina?
squeezing, tightness, heaviness, pressure
What is the location of stable angina?
substernal +/- radiation to neck, jaw, epigastrium or arms
What is the duration of stable angina?
brief, usually < 10 minutes
What are precipitating factors for stable angina? relieving factors?
stress, exercise, cold weather
relief: rest, sublingual nitrates
What are physical signs of stable angina? are they commonly seen in clinical practice?
potentially findings during acute ischemia: S3-S4, MR, inspiratory crackles, paradoxically split S2
evidence of vascular disease: carotid or renal bruits, diminished pulses, etc.
related conditions: HF, valvular heart disease, HCM
What is the most common initial test when a pt presents with stable angina? What is positive test result?
standard exercise ECG
ECG changes - ST depression
pt develops typical chest pain
can do exercise test with nuclear imaging ("cold" areas) or Echo (exercise-induced wall motion abnormalities)
What are alternative to standard exercise (treadmill) test? When are these alternatives used?
dipyridamole for pts who cant exercise or have LBBB - nuclear imaging stress test
dobutamine for pts who cant exercise or have LBBB - Echo
What is the gold standard for Dx of stable angina?
What is annual mortality rate for HIGH risk, INTERMEDIATE risk and LOW risk pts with stable angina?
HIGH risk is >3%
INTERMEDIATE risk is 1-3%
LOW risk is <1%
What are the goals of management for stable angina?
decrease frequency & severity of sx
prevention (or slowing) of disease progression
prevent adverse CV outcomes: ACS, MI, death
What aggravating factors of stable angina should be treated?
What medication therapy is used in stable angina to improve Sx?
beta blockers - reduce oxygen demand - reduces recurrent MI and mortality in pts with previous MI or previous LV systolic dysfunction
CCBs - co-admin w BBs or instead of BBs for pts in which BBs are contra
True or False: Beta-blockers in stable angina decrease mortality for all pts.
False. Beta blockers only reduce mortality for pts with previous MI or previous LV systolic dysfunction.
What is the MoA of CCBs? When are they used in Rx of stable angina?
inhibit calcium entry into cells
reduce sx by causing vasodilation
slow HR, reduce contractility
combination with BBs or as a sub when BBs are contra.
True or False: Non-dihydropyridine CCBs should be co-administered with BBs.
NO!!! FALSE!! DO NOT USE THESE WITH BETA BLOCKERS!
Non-dihydro CCBs slow conduction through AV node.
What is the MoA of nitrates? Do they show improvement in survival or prevention of MI?
converted to NO in smooth muscle cells
relax smooth muscle cells
no improvement in survival or prevention of MI
What is Ranolazine and when is it used?
late sodium channel blocker
reduces intracellular calcium
in combination with BB or as a sub. if BB is not tolerated
Rx: refractory angina who have failed other therapies
What treatments are used to prevent MI and death in pts with stable angina?
BB (for pts with previous MI or red EF)
ACE inhibitors (in pts with htn, EF <40%, CKD, DM)
When is revascularization indicated?
sx relief when medical therapy is unsuccessful
to improve survival if mortality risk is high (>50% stenosis in left main coronary artery, >70% stenosis in 3 major coronary arteries, >70% in proximal LAD + 1 other major coronary artery, survivors of SCD)
if pts prefer invasive approach over medical therapy
if there is high risk findings on noninvasive testing/high amount of myocardium at risk
previous revasc and recurrence of moderate-severe angina
survivors of SCD or serious ventricular arrythmias
What methods are used for revascularization?