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Phase2
Karl Wild and Rowena Speak
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Stable Angina
• Stable Angina - A retrosternal chest tightness or heaviness which is brought on by
exertion and relieved by rest.
• Symptoms –
 constricting discomfort in the front of the chest, arms, neck and jaw,
 Provoked by physical exertion, especially after meals and in cold, windy weather or excessive
emotion
 Relieved (within minutes) with rest or glyceryl trinitrite.
• Causes –
Mostly Atheroma.
Anaemia,
Aortic Stenosis,
Tachyarrhythmia,
Hypertrophic Cardiomyopathy
Arteritis.
Unstable Angina –
Angina of recent onset (<24hr) or a deterioration
in stable angina with symptoms occurring at rest.
Refractory Angina –
Refers to patients with severe coronary artery
disease in whom revascularization is not possible
and whose angina is not controlled by medical
therapy.
Angina Examination
Signs –
Anaemia
Thyrotoxicosis
Hyperlipidaemia
Aortic Stenosis (Ejection Systolic murmur
radiating to neck)
Check blood pressure
Angina Investigation
• 12 lead ECG
-During an attack – Transient ST depression & T
wave inversion.
• Cardiac Catheterization, CT Coronary
Angiography
• Exclude anaemia, diabetes, hyperlipidaemia,
thyrotoxicosis and arteritis
Angina Management
• Address risk factors
• Aspirin 75mg daily
• B-blocker/ Ca2+ – Atenolol/Amlodipine
Both if uncontrolled on one
• Nitrates – GTN, Isosorbide Mononitrate bd
• Ivabradine/Nicorandil
Revascularisation
• PCI –
Single vessel CAD and normal LV function
• CABG –
Triple vessel disease and abnormal LV function
Acute Coronary Syndromes
• ST Elevation Myocardial Infarction (STEMI)
• Non ST Elevation Myocardial Infarction (NSTEMI)
• Unstable Angina
• Causes –
Plaque rupture
Thrombosis
Emboli
Coronary Spasm
Vasculitis
NSTEMI
ECG changes ST depression
T Wave inversion
Could be normal
STEMI
• ECG changes –
Tall T waves
ST elevation
New LBBB
Later –
T wave inversion
Pathological Q waves
ACS symptoms •
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Acute central chest pain
Radiates neck and arm
Lasting >20 minutes
Nausea
Dyspnoea
Palpitations
ACS Signs •
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Distress, anxiety, pallor, sweatiness
Tachy/bradycardia
Hyper/hypotension
4th heart sound
Signs of HF and murmur
Later - Pericardial friction rub & peripheral
oedema
ACS Investigations
• ECG
• Bloods
• Cardiac Enzymes –
Cardiac Troponin (T & I) ^ 3 hours after onset
and peak at 24-48hr
Creatine Kinase (CK-MB) ^ 3 hours after onset,
peak within 24hr
ACS Management
NSTEMI
Oxygen
Morphine
GTN
Aspirin 300mg PO
Clopidogrel 300mg PO
Atenolol PO / Verapamil PO
Enoxaparin
More Nitrate if in pain.
High risk – GPIIb/Iia antagonist (tirofiban)
Low risk – Discharge if 12hr Trop -ve
STEMI
Oxygen
Aspirin 300mg PO
Morphine
GTN
PRIMARY PCI / Thrombolysis
Atenolol
ACS
Pathology
(Stable angina)
Cause
ECG changes
Cardiac
enzymes
(Narrowing
lumen)
Unstable
angina
Ischaemia
Nonocclusive
thrombus
No ST
elevation
-ve troponin
NSTEMI
Ischaemia/Infa Nonrction
occlusive
thrombus
No ST
elevation
+ve
troponin
STEMI
Transmural
infarction
ST elevation
+ve
troponin
Occlusive
thrombus
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Hypertension (HTN)
• Essential (primary) HTN
= idiopathic
• Secondary HTN =
something is causing it
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HTN: causes of secondary
• Renal disease: intrinsic, renovascular
• Endocrine: Cushing’s, Conn’s, Phaeochromocytoma,
Acromegaly, Hyperparathyroidism
• Coarctation of the aorta
• Pre-eclampsia and HTN in pregnancy
• Drugs and toxins: alcohol, cocaine, ciclosporin, decongestants,
adrenergic medications, oral contraceptives, corticosteroids,
liquorice
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HTN: symptoms
• Usually asymptomatic
• Headaches, paroxysmal sweats or palpitations
= think phaeochromocytoma (tumour of the
adrenal medulla)
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HTN: diagnosis
• GP surgery BP measurements of adults at least every 5 years
White coat syndrome = patients have elevated BP in a clinical setting but not
in other settings due to anxiety experienced during a clinic visit.
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ABPM = ambulatory blood pressure monitoring
HBPM = home blood pressure monitoring
Cardiovascular risk assessment
HTN retinopathy screening
ECG to look for LVH
Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids
Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine
ratio.
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HTN: stages
• Stage 1 - BP in surgery/clinic is ≥140/90 mm
Hg and ABPM or HBPM is ≥135/85 mm Hg.
• Stage 2 - BP in surgery/clinic is ≥160/100 mm
Hg and ABPM or HBPM is ≥150/95 mm Hg.
• Severe - BP in surgery/clinic is ≥180/110 mm
Hg or higher.
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HTN: lifestyle interventions
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Lower salt intake
Reduce alcohol consumption
Stop smoking
Do more exercise
Be less stressed
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HTN: initiation of treatment
• Offer step 1 treatment to
people aged under 80 with
stage 1 hypertension and
one or more of:
a) target organ damage
b) established cardiovascular
disease
c) renal disease
d) diabetes
e) 10-year cardiovascular risk
equivalent to 20%
• Offer step 1 treatment to
people of any age with
stage 2 hypertension
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HTN: treatment
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Heart failure
• A complex syndrome that can result from any
structural or functional cardiac disorder that
impairs the ability of the heart to function as a
pump to support a physiological circulation.
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HF: aetiology
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Ischaemic heart disease
Cardiomyopathy
HTN
Diseases of the heart
valves
• Pericardial disease
• Arrhythmias
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Alcohol
Cocaine
Chemo
Severe anaemia
Thyroid disease
Idiopathic
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HF: symptoms
Left
• Exertional dyspnoea
• Orthopnoea
• Paroxysmal nocturnal
dyspnoea (PND)
• Fatigue
Right
• Swollen ankles
• Fatigue
• Anorexia
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HF: signs
Left
• Cardiomegaly
• Third and fourth heart
sounds
• Tachycardia
• Crepitations in lung bases
Right
• Raised JVP
• Hepatomegaly
• Pitting oedema
• Ascites
The Peer Teaching Society is not liable for false or misleading information…
The Peer Teaching Society is not liable for false or misleading information…
HF Investigations
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Chest X ray
Bloods
B-type Natriuretic Peptide
ECG
Transthoracic echocardiogram
Chronic HF Management
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Diuretics – Furosemide
ACE-I – Ramipril / ARB – Candesartan
B-Blocker – Atenolol
Spironolactone
Digoxin
Vasodilators – Hydralazine & Isosorbide
Dinitrate
Acute HF Management
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Oxygen
Diamorphine IV
Furosemide IV
GTN spray
If systolic BP >100mmHg IV nitrate
HF Question
A 75 year-old woman is brought to the Emergency Department
by ambulance following an emergency call at 4 am.
She is pain-free but very breathless.
She has previously been diagnosed with congestive cardiac
failure and is receiving drug treatment from her General
Practitioner.
GOOD LUCK!!!