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Flashcards in Week 126 - Chronic Stable Angina Deck (30):
1

What are some of the differential diagnoses for angina?

• MI

• PE

• Reflux Oesophagitis

• Pneumothorax

• Aortic Dissection

2

What investigations should be performed for a suspected case of angina?

ECG, Blood profile, Exercise Stress Test, Angiography

3

What are some of the lifestyle management options for chronic stable angina?

• Smoking Cessation

• Diet

• Exercise

4

What are the medical treatment options for chronic stable angina?

• Drugs-
- Antiplatelets
- Beta-blockers
- Statins
- Nitrates
- Calcium channel blockers

• Treat related conditons-
- Anaemia
- Diabetes

5

What are the revascularisation options for chronic stable angina?

• Percutaneous coronary intervention - Plain old balloon angioplasty, bare metal stents, drug eluting stents.

• Coronary Artery Bypass Surgery

6

Coronary Artery Bypass Surgery for Chronic Stable Angina: What are the indications, risks and benefits?

Indications -
- 3VD, 2VD with LV impairment or LMS.

Risks -
- Risk stratification, unit results, individual results.

Benefits - 
- Symptoms and prognosis.

7

What is a the definition of Hypoxia?

A lack of oxygen resulting in a decrease in oxidative respiration leading to tissue damage.

8

What is the definition of ischaemia?

• A lack of blood supply from a stenotic/occluded artery or reduced venous drainage causes ischaemia.

• This causes a lack in oxygen and metabolites, causes cell injury more rapidly than hypoxia.

9

What is the definition of infarction?

Irreversible cell death due to hypoxia or ischaemia.

10

What are the four main pathophysiological outcomes of cell injury?

• Decreased ATP

• Membrane damage

• Increased intracellular calcium

• Increased oxygen derived from free radicals

11

What is the impact of decreased ATP during cell injury?

• Decreased activity of Na/K pump leads to;
- Influx of Ca, H2O, Na
- Eflux of K leading to cell swelling, loss of microvilli.

• Increased anaerobic glycolysis leading to;
- Decreased pH and Glycogen

• Detachment of ribosomes;
- Decreased protein synthesis.

12

What occurs to the membrane during cell damage?

• Decreased ATP leads to decreased production of phospholipids.

• Influx of Ca activates phospholipases and proteases leading to destruction of cytoskeleton.

13

During cell damage their is an influc of Ca, what effect does this have on the cell?

• ATPase causing decrease in ATP.

• Increase in phospholipases, causes a decrease in phospholipids.

• Increase in proteases, causes destruction of membrane and cytoskeleton.

• Increase in endonucleases, leading to chromatin breakdown.

14

What is iscahemia-reperfusion injury? What are the hypothesis for its mechanism?

• Some cells which are reversibly damaged for ischaemia may then die when blood flow returns.

• Oxygen free radicals, Mitochondrial permeability transition, inflammation associated injury, Complement.

15

What is atheroscleorsis?

• Atheroma is the accumulation of lipid and fibrous tissue within the antima of the artery.

• These localised collections are called 'plaques'.

16

What is the difference between a stable and unstable plaque?

• Stable -
- Concentric, rish in firbous stroma, rich in smooth muscle.

• Unstable - 
- Eccentric, rich in lipid, Macrophages, Inflammation, endothelial cell injury.

17

What are the risk factors for atherosclerosis?

• Age, Gender, Family history

• Smoking, Hypertension, Hyperlipidaemia, Diabetes Melitus.

18

What are the four life-threatening causes of chest pain that you should never miss?

• MI

• PE

• Tension pneumothorax

• Dissecting aortic aneurism

19

What is the definition of stable angina?

• Reversible ischaemia to myocardiam brought about due to increased stress and relieved by rest.

20

What are the four classifications of stable angina?

• Class I - Strenuous or protracted exercise.

• Class II - Slight limitation with vigorous exercise.

• Class III - Marked limitation with activities of everyday living.

• Class IV - Inability to perform daily activites.

21

What initial investogations should be performed for stable angina?

• ECG

• Bloods

• CXR - For determining causes of chest pain.

22

What is the drug-therapy for chronic stable angina?

• Nitrates

• Beta-Blockers

• Calcium Channel Blockers

• Longer-acting nitrates

• Potassium channel activators

• Ivabradine

• Ranolazine

23

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Nitrates?

• 1st line choice for rapid relievement of symptoms, can also be used as prophylaxis.

• Release of NO to activate cAMP which causes smooth muscle relaxation and subsequent vasodilation.

• Sideffects - Hypotension, Headache, Flushing.

• Contraindications - Hypotension, Aortic and mitral stenosis, Hypertrophic cardiomyopathy.

24

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Beta-blockers?

• 1st line treatment.

• Causes reduction in sympathetic stimulation to cause a reduction in heart rateand myocardial contractability.

• Side-effects - Bronchospasm, bradycardia, cold extremities, numbness, sleep disturbance, fatigue, sexual dysfunction.

• Contra-indications - Asthma, bradycardia, uncontrolled heart failure, 2˚ and 3˚ heart block, severe peripheral artery disease.

25

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Calcium Channel Blockers (dihydropyridines)?

• Amlodipine, Nifedipine, Felodipine.

• 2nd-line addition to Beta-blockers.

• Smooth muscle relaxation by inhibiting influx of calcium ions.

• Side-effects: Flushing, headaches, dizziness, ankle oedema, hypotension.

• Contraindications: Uncontrolled heart failure, MI in past month, significant aortic stenosis.

26

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Calcium channel blockers (Non-dihydropyridines)?

• Verapamil, Diltiazem.

• Option for patiens where beta-blockers are contraindicated.

• Conduction of AV node, has rate limiting mechanism.

• Side-effects - SA/AV block, constipation.

• Contraindications - 2˚/3˚ heart block, uncontrolled heart failure.

27

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Longer-acting nitrates? 

• Added into beta-blocker for symptom control.

• Release of NO to activate cAMP to cause smooth muscle relaxation and subsequent vasodilation.

• Side-effects: Hypotension, headache, flushing.

• Contra-indications: Hypotension, aortic and mitral stenosis, hypertrophic cardiomyopathy.

28

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Potassium-channel activator?

• Nicorandil

• 3rd-line added in drug.

• NO donor to activate cAMP, smooth muscle relaxation, vasodilation.

• Opens K+ channels resulting in decreased Ca influx.

• Side-effects: Headache, Hypotension, GI irritation.

• Contra-indications: Left ventricular failure, hypotension.

29

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Ivabradine?

• 3rd line treatment.

• Blocks a pacemaker or 'funny' current channel in SA node.

• Side-effects: Visual disturbances, Bradycardia, 1˚ heart block, Headache and dizziness.

• Contraindications: Bradycardia, 2˚/3˚ heart block, Acute MI.

30

Chronic Angina Medical Therapy: What is the role in treatment, mechanism, side-effects and contraindications of Ranolazine?

• Add-on for symptomatic control if no relief from previous medical therapy.

• Inhibits 'late' sodium channels - resulting in decreased influx of Ca resulting in relaxation of smooth muscle.

• Side-effects: Constipation, Nausea and Vomitting, Dizziness and headache.

• Contradindications - Moderate to severe hepatic impairment.