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Flashcards in Stable Angina Deck (98):
1

What is angina?

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

2

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

Angina

3

What is myocardial ischaemia?

Lack of oxygen to the heart

4

What is a lack of oxygen to the heart called?

Myocardial ischaemia

5

What is ischaemia?

Restriction in blood supply to tissues causing a shortage of oxygen

6

What is restriction in blood supply to tissues causing a shortage of oxygen called?

Ischaemia

7

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

8

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

9

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)

10

What causes reduced oxygen transport?

Anaemia

11

What leads to pathologically increased myocardial oxygen demand?

Left ventricular hypertrophy (LVH) as seen in significant hypertension, aortic stenosis and hypertrophic cardiomyopathy

Thyrotoxicosis

12

What does LVH stand for?

Left ventricular hypertrophy

13

What is hypertrophic cardiomyopathy?

Portion of the heart becomes thickened without a known cause

14

What is it called when a portion of the heart becomes thickened without a known cause?

Hypertrophic cardiomyopathy

15

What is thyrotoxicosis?

Excess of thyroid hormone in the body

16

What is excess of thyroid hormone in the body called?

Thyrotoxicosis

17

What is the most common cause of angina?

Coronary atheroma

18

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

19

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

20

What is arteritis?

Inflammation of the walls of the arteries

21

What is inflammation of the walls of the arteries called?

Arteritis

22

What is the typical distribution of pain due to angina?

Along the chest to the left arm

23

How would you describe the process of atherosclerosis?

Progressive process

24

When does atherosclerosis go from no symptoms to stable angina to acute coronary syndromes?

25

Where does a lot of the diagnosis for angina come from?

The history

26

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

27

What kind of things are needed to be known about angina pain?

Site of pain

Character of pain

Radiation sites

Aggravating

Relieving factors

28

What is the site of pain?

Retrosternal

29

What is the character of the pain?

Often tight band/pressure/heaviness

30

What are the radiation sites of the pain?

Neck and/or into jaw, down arms

31

What aggravates the pain?

Exertion and emotional stress

32

What are relieving factors for the pain?

Rapid improvement with GTN or physical rest

33

When can myocardial ischaemia occur without chest pain?

In the elderly or with diabetes mellitus due to reduced pain sensation

34

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

35

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

36

What is required to differentiate angina from other possible causes for the pain?

Differential diagnosis

37

What are other systems that cause similar pain to angina?

Cardiovascular

Respiratory

Musculoskeletal

GI

38

What are some cardiovascular causes that are similar to angina but the pain has different characteristics?

Aortic dissection

Pericarditis

39

What are some respiratory causes that are similar to angina but the pain has different characteristics?

Pneumonia

Pleurisy

Peripheral pulmonary emboli

40

What are some musculoskeletal causes that are similar to angina but the pain has different characteristics?

Cervical disease

Costochondritis

Muscle spasm

Strain

41

What are some GI causes that are similar to angina but the pain has different characteristics?

Gastro-oesophageal reflux

Oesophageal spasms

Peptic ulceration

Biliart colic

Cholecystitis

Pancreatitis

42

What is retrosternal?

Behind the breastbone (sternum)

43

What are the classes of angina severity?

I

II

III

IV

44

What is the first class of angina severity?

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

45

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

46

What is the third class of angina severity?

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

47

What is the fourth class of angina severity?

Symptoms on any activity, getting washed/dressed causing symptoms

48

What are some risk factors for coronary artery disease?

Non-modifiable

Age
Gender
Creed
Family history and genetic factors

 

Modifiable

Smoking
Lifestyle (exercise and diet)
Diabetes mellitus
Hypertension
Hyperlipidaemia

49

What are some things seen in the examination for angina?

Tar stains on fingers

Obesity

Xanthalasma and corneal arcus (hypercholesterolaemia)

Hypertension

 

50

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

51

What investigations are done to diagnose angina?

Bloods

Chest X-ray

Electrocardiogram

Exercise tolerance test (ETT)

Myocardial perfusion imaging

CT coronary angiography

Cardiac catheterisation/coronary angiography (invasive)

52

What bloods are done to diagnose angina?

Full blood count

Lipid profile and fasting glucose

Electrolytes

Liver and thyroid tests

53

Why are chest X-rays useful for diagnosing angina?

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

54

What can an electrocardiogram show?

Evidence of prior myocardial infarction or left ventricular hypertrophy

55

What is seen on an electrocardiogram for a previous myocardial infarction?

Pathological Q waves

56

What is seen on an electrocardiogram for left ventricular hypertrophy?

High voltages

Lateral ST-segment depression

57

What does ETT stand for?

Exercise tolerance test

58

What is a problem with an exercise tolerance test?

Relies on ability to walk long enough to produce sufficient CV stress

59

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

60

What is seen in an exercise tolerance test when angina is positive?

Typical symptoms and ST-segment depression

61

What does myocardial perfusion imaging allow?

Localisation of ischaemia and assessing size of area affected

62

What are disadvantages of myocardial perfusion imaging?

Expensive

Uses radioactivity

Depends on availability

 

63

What is an invasive investigation for angina?

Cardiac catheterisation/coronary angiography

64

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

65

What does PCI stand for?

Percutaneous coronary intervention

66

What are the most common kinds of percutaneous coronary intervention (PCI)?

Angioplasty and stenting or coronary artery bypass graft (CABG) surgery

67

What does CABG stand up for?

Coronary artery bypass graft

68

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)

69

What is the condition when in a myocardial perfusion imaging the tracer is seen at rest but not after stress?

Ischaemia

70

What is the condition when in a myocardial perfusion imaging the tracer is not seen at rest or after stress?

Infarction

71

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)

72

What is an angiography?

A type of X-ray used to look at blood vessels

73

What are treatment strategies for angina?

Addressing risk factors

Drugs to reduced disease progression

Drugs to reduce symptoms

Revascularisation (if symptoms are not controlled)

74

What are examples of drugs used to reduced disease progression of angina?

Statins

ACE inhibitors

Aspirin

75

When should statins be considered for treatment of angina?

If total cholesterol > 3.5mmol/L

76

How do statins help to reduce angina?

Reduced LDL-cholesterol deposition in atheroma and also stabilises atheroma reducing plaque rupture and acute coronary syndrome

77

When should ACE inhibitors be used to prevent disease progression of angina?

Increased CV risk and atheroma

78

How do ACE inhibitors help to prevent disease progression of angina?

Stabilise endothelium and also reduce plaque rupture

79

How does the aspirin prevent disease progression of angina?

May not directly affect plaque but does protect endothelium and reduces platelet activation/aggregation

80

What are drugs used to reduce disease symptoms of angina?

Beta blockers

Ca2+ channel blockers

Ik channel blockers

Nitrates

K+ channel blockers

81

Why are beta blockers used to reduce symptoms of angina?

Reduces myocardial work and achieves resting heart rate < 60bpm

82

How do CCB reduce symptoms of angina?

Centrally acting to achieve resting heart rate < 60bpm

Peripherally acting produces vasodilation

83

What is an example of a CCB used to treat symptoms of angina?

Diltiazem/verapamil for central

Amlodipine and felodipine for peripheral

84

How do Ik channel blockers reduces symptoms of angina?

Reduces sinus node rated to achieve resting heart rate < 60bpm

85

What is an example of a Ik channel blocker to treat symptoms of angina?

Ivabridine

86

How do nitrates help reduce symptoms of angina?

Produce vasodilation

87

How are nitrates used?

Short or prolonged acting tablets, patches or as rapidly acting sublinguinal GTN spray for immediate use

88

What is an example of a potassium channel blocker used to reduce the symptoms of angina?

Nicorandil

89

90

What are methods for revascularisation?

Percutaneous coronary intervention (PCI)

Coronary artery bypass grafting (CABG)

91

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

92

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)

93

Does percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have greater risks?

Coronary artery bypass grafting (CABG)

94

What are advantages of coronary artery bypass grafting (CABG)?

Good long lasting benefits, 80% symptoms free 5 years later

95

What is percutaneous coronary intervention (PCI)?

Non-invasive procedure that uses a catheter to place a stent to open up blood vessels

96

What is a non-invasive procedure that uses a catheter to place a stent to open up blood vessels?

Percutaneous coronary intervention (PCI)

97

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

98

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)

Decks in Cardiovascular System Class (41):