stable angina

Question 1

whats the definition of stable angina?

Answer 1

a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis

Question 2

what are the three important things about angina

Answer 2

excertion
treatment is symptomatic
higher chance of angina with people with higher risk of cv disease

Question 3

how much lumen is there if you have stable angina?

Answer 3

obstructive plaque >70% lumen

Question 4

what would the situation of plaque be if you have acute coronary syndromes?

Answer 4

Spontaneous plaque
rupture & local
thrombosis, with
degrees of occlusion

Question 5

what should you ask when taking history for suspected angina?

Answer 5

Site of pain (watch for patient gestures): retrosternal
Character of pain: often tight band/pressure/heaviness.
Radiation sites: neck and/or into jaw, down arms.
Aggravating e.g. with exertion, emotional stress
& relieving factors e.g. rapid improvement with GTN or physical rest.

Question 6

wht are the differential diagnosis for chest pain in cardiovascular?

Answer 6

Aortic dissection (intra-scapular “tearing”), pericarditis

Question 7

wht are the differential diagnosis for chest pain in Respiratory?

Answer 7

Pneumonia, pleurisy, peripheral pulmonary emboli (pleuritic)

Question 8

wht are the differential diagnosis for chest pain in Musculoskeletal?

Answer 8

Cervical disease, costochondritis, muscle spasm or strain

Question 9

wht are the differential diagnosis for chest pain in GI?

Answer 9

Gastro-oesphageal reflux, oesophageal spasm, pep

Question 10

there are 4 levels of severity for stable angina whats the first one?

Answer 10

Ordinary physical activity does not cause angina, symptoms only on significant exertion.

Question 11

there are 4 levels of severity for stable angina whats the second one?

Answer 11

Slight limitation of ordinary activity, symptoms on walking 2 blocks or > 1 flight of stairs.

Question 12

there are 4 levels of severity for stable angina whats the third one?

Answer 12

Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs.

Question 13

there are 4 levels of severity for stable angina whats the 4th one and most severe?

Answer 13

Symptoms on any activity, getting washed/dressed causes symptoms.

Question 14

what are the risk factors for coronary artery disease?

Answer 14

Age, gender, creed, family history & genetic factors.
Modifiable
Smoking
Lifestyle- exercise & diet
Diabetes mellitus (glycaemic control reduces CV risk)
Hypertension (BP control reduces CV risk)
Hyperlipidaemia (lowering reduces CV risk)

Question 15

what kind of things would indictae stable angina when examining a patient?

Answer 15

Tar stains on fingers
Obesity (centripedal)
Xanthalasma and corneal arcus (hypercholesterolaemia)
Hypertension,
Abdominal aortic aneurysm arterial bruits, absent or reduced peripheral pulses.
Diabetic retinopathy, hypertensive retinopathy on fundoscopy.

Question 16

how would you investigate for stable angina?

Answer 16

Bloods
Full blood count, lipid profile and fasting glucose; Electrolytes, liver & thyroid tests would be routine.

CXR
Often helps show other causes of chest pain and can help show pulmonary oedema.

Electrocardiogram
normal in over 50% of cases
may be evidence of prior myocardial infarction i.e. pathological Q-waves.
may be evidence of left ventricular hypertrophy i.e. high voltages, lateral ST-segment depression or “strain pattern”.

Exercise tolerance test/ETT
Often can confirm diagnosis of angina.
Relies on ability to walk for long enough
to produced sufficient CV stress.
Typical symptoms and ST-segment depression for positive test.
-ve ETT doesn’t exclude significant
coronary atheroma but if negative at high workload overall prognosis is good

Myocardial perfusion imaging
Superior to ETT in detection of CAD, localisation of ischaemia and assessing size of area affected.
Expensive, involves radioactivity; depending on availability used where ETT not possible/equivocal.
Either exercise or pharmacological stress: adenosine, dipyridamole or dobutamine .

Computed tomography (CT) coronary angiography

Question 17

what is invasive angiography?

Answer 17

Early or strongly positive ETT (suggests multi-vessel ds).
Angina refractory to medical therapy.
Diagnosis not clear after non-invasive tests.
Young cardiac patients due to work/life effects.
Occupation or lifestyle with risk e.g. drivers etc.

Question 18

what are the treaatment for stable angina for influencing disease progression

Answer 18

Statins: consider if total cholesterol >3.5 mmol/l.
Reduce LDL-cholesterol deposition in atheroma and also stabilise atheroma reducing plaque rupture and ACS.

ACE inhibitors: if increased CV risk and atheroma
Stabilise endothelium and also reduce plaque rupture.

Aspirin; 75mg or clopidogrel if intolerant of aspirin.
May not directly affect plaque but does protect endothelium and reduces of platelet activation/aggregation

Question 19

what is the treatmenet for relief of symptoms

Answer 19

ß-blockers; achieve resting hr <60 bpm.
Reduced myocardial work and have anti-arrhythmic effects

Ca2+ channel blockers; achieve resting hr <60 bpm.
Central acting eg diltiazem/verapamil if ß-blockers C-I

Ik channel blockers; achieve resting hr <60 bpm.
Ivabridine is a new medication which reduces sinus node rate

Ca2+ channel blockers; produce vasodilatation
Peripherally acting dihydropyridines eg amlodipine, felodipine

Nitrates; produce vasodilatation
Used as short or prolonged acting tablets, patches or as rapidly acting sublingual GTN spray for immediate use.

K+ channel blockers; nicorandil
Nitrate molecule and K+ channel helpful in ‘pre-conditioning’

Question 20

what are some treatment strategies for stable angina?

Answer 20

Percutaneous coronary intervention (PCI)

Coronary artery bypass surgery (CABG)