What is angina?
A discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis
What is a discomfort in the chest and/or adjacent areas associated with myocardial ischaemia but without myocardial necrosis called?
What is myocardial ischaemia?
Lack of oxygen to the heart
What is a lack of oxygen to the heart called?
What is ischaemia?
Restriction in blood supply to tissues causing a shortage of oxygen
What is restriction in blood supply to tissues causing a shortage of oxygen called?
What is the pathophysiology of myocardial ischaemia and resultant angina symptoms?
Mismatch between supply of oxygen and metabolites to myocardium and the myocardial demand for them
What is the mismatch between nutrients delivered to the myocardium and the demand for them due to?
Most commonly due to a reduction in coronary blood flow to the myocardium
Uncommonly due to reduced oxygen transport
Uncommonly due to pathologically increased myocardial demand
What can casue a reduction in coronary blood flow to the myocardium?
Obstructive coronary atheroma (very common)
Coronary artery spasm (uncommon)
Coronary inflammation/arteritis (very rare)
What causes reduced oxygen transport?
What leads to pathologically increased myocardial oxygen demand?
Left ventricular hypertrophy (LVH) as seen in significant hypertension, aortic stenosis and hypertrophic cardiomyopathy
What does LVH stand for?
Left ventricular hypertrophy
What is hypertrophic cardiomyopathy?
Portion of the heart becomes thickened without a known cause
What is it called when a portion of the heart becomes thickened without a known cause?
What is thyrotoxicosis?
Excess of thyroid hormone in the body
What is excess of thyroid hormone in the body called?
What is the most common cause of angina?
Why does coronary atheroma cause angina?
On activity with the increased myocardial oxygen demand obstructed coronary blood flow leads to muocardial ischaemia and tehn the symptoms of angina
Myocardial oxygen demand increases in situations where heart rate and blood pressure rise, such as exercise, anxiety/emotional stress and after a large meal
When does myocardial oxygen demand increase?
In situations where heart rate and blood pressure rise, such as exercise, anxiety/emotional stress and after a large meal
What is arteritis?
Inflammation of the walls of the arteries
What is inflammation of the walls of the arteries called?
What is the typical distribution of pain due to angina?
Along the chest to the left arm
How would you describe the process of atherosclerosis?
When does atherosclerosis go from no symptoms to stable angina to acute coronary syndromes?
Where does a lot of the diagnosis for angina come from?
What is it essential to establish about the pain from angina?
The character of the pain to differentiate it from other causes of chest pain
What kind of things are needed to be known about angina pain?
Site of pain
Character of pain
What is the site of pain?
What is the character of the pain?
Often tight band/pressure/heaviness
What are the radiation sites of the pain?
Neck and/or into jaw, down arms
What aggravates the pain?
Exertion and emotional stress
What are relieving factors for the pain?
Rapid improvement with GTN or physical rest
When can myocardial ischaemia occur without chest pain?
In the elderly or with diabetes mellitus due to reduced pain sensation
What other symptoms are present when pain is not for myocardial ischaemia?
Breathlessness on exertion
Excessive fatigue on exertion for activity undertaken
Near syncope on exertion
What are examples of features that make angina less likely?
Sharp/stabbing pain (pleuritic or pericardial)
Associated with body movements or respiration
Very localised (pinpoint site)
Superficial with/or without tenderness
No pattern to pain
Begins sometimes after exercise
Lasting for hours
What is required to differentiate angina from other possible causes for the pain?
What are other systems that cause similar pain to angina?
What are some cardiovascular causes that are similar to angina but the pain has different characteristics?
What are some respiratory causes that are similar to angina but the pain has different characteristics?
Peripheral pulmonary emboli
What are some musculoskeletal causes that are similar to angina but the pain has different characteristics?
What are some GI causes that are similar to angina but the pain has different characteristics?
What is retrosternal?
Behind the breastbone (sternum)
What are the classes of angina severity?
What is the first class of angina severity?
Ordinary physical activity does not cause angina, symptoms only significant on exertion
What is the second class of angina severity?
Slight limitations of ordinary activity, symptoms on walking 2 blocks or more than 1 flight of stairs
What is the third class of angina severity?
Marked limitation, symptoms on walking only 1-2 blocks or 1 flight of stairs
What is the fourth class of angina severity?
Symptoms on any activity, getting washed/dressed causing symptoms
What are some risk factors for coronary artery disease?
Family history and genetic factors
Lifestyle (exercise and diet)
What are some things seen in the examination for angina?
Tar stains on fingers
Xanthalasma and corneal arcus (hypercholesterolaemia)
What are some signs during the examination of exacerbating or associated conditions?
Pallor of anaemia
Tachycardia, tremor, hyper-reflexia of hyperthyroidism
Ejection systolic murmur, plateau pulse of aortic stenosis
Pansystolic murmur of mitral regurgitation
Signs of heart failure such as basal crackles, elevated JVP, peripheral oedema
What investigations are done to diagnose angina?
Exercise tolerance test (ETT)
Myocardial perfusion imaging
CT coronary angiography
Cardiac catheterisation/coronary angiography (invasive)
What bloods are done to diagnose angina?
Full blood count
Lipid profile and fasting glucose
Liver and thyroid tests
Why are chest X-rays useful for diagnosing angina?
Often helps to show other causes of chest pain and can help show pulmonary oedema
What can an electrocardiogram show?
Evidence of prior myocardial infarction or left ventricular hypertrophy
What is seen on an electrocardiogram for a previous myocardial infarction?
Pathological Q waves
What is seen on an electrocardiogram for left ventricular hypertrophy?
Lateral ST-segment depression
What does ETT stand for?
Exercise tolerance test
What is a problem with an exercise tolerance test?
Relies on ability to walk long enough to produce sufficient CV stress
What can you say about an exercise tolerance test coming back negative and angina?
Doesn't exclude significant amounts of atheroma but if negative at a high workload overall prognosis is good
What is seen in an exercise tolerance test when angina is positive?
Typical symptoms and ST-segment depression
What does myocardial perfusion imaging allow?
Localisation of ischaemia and assessing size of area affected
What are disadvantages of myocardial perfusion imaging?
Depends on availability
What is an invasive investigation for angina?
Cardiac catheterisation/coronary angiography
What does cardiac catheterisation/coronary angiography provide?
Definition of coronary anatomy with sites, distribution and nature of atheromatous disease
Can decide whether medication alone or percutaneous coronary intervention (PCI) is needed
What does PCI stand for?
Percutaneous coronary intervention
What are the most common kinds of percutaneous coronary intervention (PCI)?
Angioplasty and stenting or coronary artery bypass graft (CABG) surgery
What does CABG stand up for?
Coronary artery bypass graft
What is the process of myocardial perfusion imaging?
1) Radionuclide tracer injected (IV) at peak stress and images obtained
2) Images obtained at rest
3) Comparison between stress and rest images
4) Normal myocardium takes up tracer (tracer seen at rest but not after stress is ischaemia, tracer seen neither at rest or after stress is infarction)
What is the condition when in a myocardial perfusion imaging the tracer is seen at rest but not after stress?
What is the condition when in a myocardial perfusion imaging the tracer is not seen at rest or after stress?
When would an invasive angiography be used?
Early or strongly positive ETT
Angina refractory to medical therapy
Diagnosis not clear after non-invasive tests
Yound cardiac patients due to work/life effects
Occupation or lifestyle with risk (such as divers)
What is an angiography?
A type of X-ray used to look at blood vessels
What are treatment strategies for angina?
Addressing risk factors
Drugs to reduced disease progression
Drugs to reduce symptoms
Revascularisation (if symptoms are not controlled)
What are examples of drugs used to reduced disease progression of angina?
When should statins be considered for treatment of angina?
If total cholesterol > 3.5mmol/L
How do statins help to reduce angina?
Reduced LDL-cholesterol deposition in atheroma and also stabilises atheroma reducing plaque rupture and acute coronary syndrome
When should ACE inhibitors be used to prevent disease progression of angina?
Increased CV risk and atheroma
How do ACE inhibitors help to prevent disease progression of angina?
Stabilise endothelium and also reduce plaque rupture
How does the aspirin prevent disease progression of angina?
May not directly affect plaque but does protect endothelium and reduces platelet activation/aggregation
What are drugs used to reduce disease symptoms of angina?
Ca2+ channel blockers
Ik channel blockers
K+ channel blockers
Why are beta blockers used to reduce symptoms of angina?
Reduces myocardial work and achieves resting heart rate < 60bpm
How do CCB reduce symptoms of angina?
Centrally acting to achieve resting heart rate < 60bpm
Peripherally acting produces vasodilation
What is an example of a CCB used to treat symptoms of angina?
Diltiazem/verapamil for central
Amlodipine and felodipine for peripheral
How do Ik channel blockers reduces symptoms of angina?
Reduces sinus node rated to achieve resting heart rate < 60bpm
What is an example of a Ik channel blocker to treat symptoms of angina?
How do nitrates help reduce symptoms of angina?
How are nitrates used?
Short or prolonged acting tablets, patches or as rapidly acting sublinguinal GTN spray for immediate use
What is an example of a potassium channel blocker used to reduce the symptoms of angina?
What are methods for revascularisation?
Percutaneous coronary intervention (PCI)
Coronary artery bypass grafting (CABG)
How is percutaneous coronary intervention (PCI) done for revascularisation?
If stent is used aspirin and clopidogrel are taken whilst endothelium covers the stent and it is no longer seen as a foreign body with risk of thrombosis
What are disadvantages of percutaneous coronary intervention (PCI)?
No evidence improves prognosis in stable death (only good to reduce symptoms)
Small risk of procedural complications (such as death or myocardial infarction)
Risk of restenosis (reoccurence of narrowing artery)
Does percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have greater risks?
Coronary artery bypass grafting (CABG)
What are advantages of coronary artery bypass grafting (CABG)?
Good long lasting benefits, 80% symptoms free 5 years later
What is percutaneous coronary intervention (PCI)?
Non-invasive procedure that uses a catheter to place a stent to open up blood vessels
What is a non-invasive procedure that uses a catheter to place a stent to open up blood vessels?
Percutaneous coronary intervention (PCI)
What is coronary artery bypass grafting (CABG)?
Surgical procedure used to treat coronary heaert disease by diverting blood around narrowed parts of major arteries to improve blood flow to the heart
What is a surgical procedure used to treat coronary heaert disease by diverting blood around narrowed parts of major arteries to improve blood flow to the heart?
Coronary artery bypass grafting (CABG)