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Patient Presentation
Beebee Meeajun
Demographics:
Mr PG
63 years old
Caucasian
Presenting Complaint:
Tingling in chest
History of presenting complaint:
Admitted via A&E on 2/9/03
Paraesthesiae
Symptoms from previous 5 days
Cold weather
No pain/SOB/palpitations/nausea
GTN
Episodes last up half hour
1st experience
Tests
Past History:
Hypertension
Blood clot in eye
TB 40 years ago
Headaches
Speech problem
CVS risk factors:
Age
Male
Hypertensive
Diabetic
System Enquiries:
No signs of:
JACCOL
Neurological problems
Respiratory difficulties
GI / GU / MS problems
Drug History:
No known allergies
Aspirin (od)
Amlodepine (od)
Herbal tablets
GTN
Social History:
Priest
Lives alone in house
Hobbies-music, reading
Drinks 3-4 units alcohol
Non-smoker
No use of recreational drugs
Family History:
Sister lives in Ireland
Father died in accident
Mother died of cancer
No family history of CVD
Investigations for Angina
Pectoris
Linzi Craxford
What was done?
Basic
FBC (normal)
Cholesterol (normal)
U & E’s (normal)
LFT’s (normal)
Fasting Glucose (9.1 mmol/L)
CRP (normal)
CK, Trop T and cardiac enzymes (normal)
What was done?
Specialised
Resting ECG (normal)
Exercise tolerance test (ST depression)
Chest X-ray (normal)
Catheterisation and Angiogram (? Results)
What else can be done?
Basic
Thyroid tests for low TSH and high T3 & T4
Specialised
Cardiac scintigraphy
Echocardiography
MANAGEMENT
Initially:
Reassurance
treat underlying problems
other cp-existing problems correctly
managed
risk factors evaluated and eliminated
where possible
Prognostic therapies:
Aspirin - 75mg daily
- decreases risk of coronary events in
patients with coronary artery disease.
Lipid-lowering agents
- used if total cholesterol is greater
than 4.8mmol/L
Symptomatic treatment:
Glyceryl trinitrate (GTN)
- given sublingually for acute attacks
- taken before exertion
If angina is frequent or occurs with only
modest exertion prophylactic therapy
should be given
Prophylactic treatments
Beta-adrenergic blocking drugs
- reduce heart rate and force of
ventricular contraction
Calcium antagonists
- relax coronary arteries and reduce the
force of left ventricular contraction
Nitrates
- reduce venous and intra cardiac
pressures, dilate coronary arteries and reduce
impedance to emptying left ventricle
Nicordial
- nitrate-like activity with potassium
channel blockade
- useful when there are
contraindications to beforementioned agents
Coronary Angioplasty
Localized atheromatous lesions are dilated
at cardiac catheterization using small
inflatable balloons
gives more complete relief than medical
therapy but is associated with a higher
rate of myocardial infarction OR bypass
surgery as a result of the procedure
Surgical management
Coronary artery bypass grafting (CABG)
- relief is achieved in 90% cases
- suitable if medical treatement does
not eliminate symptoms or if patient
not suitable for angioplasty
Causes & Risk Factors
Dornu Lebari
Pathophysiology of
Ischemia
 Mismatch of myocardial oxygen
supply and demand.
 Atherosclerotic plaques narowing
vessel lumen.
 Recent evidence supports idea of
fixed vessel narrowing and abnormal
vascular tone .
Dornu Lebari
Causes of Ischemia
Inappropriate vasoconstriction
Platelet aggregation
Producing reduced oxygen supply to the
myocardium.
Atherosclerotic plaques.
Dornu Lebari
Pathophysiology in Anginal
syndromes
 Patent lumen, no platelet
aggregation, normal endothelium.
Lumen is narrowed by plaque,
inappropriate vasoconstriction.
Plaque rupture, platelet
aggregation, thrombus,
unopposed vasoconstriction.
No overt plaques, intense
vasospasm.
Images courtesy of “Pathophysiology of Heart Disease” edited by Leonard S. Lilly.
Dornu Lebari
Risk factors
Alcohol drinking
Cigarette smoking
Hypercholesterolemia
Hypertension
Diabetes
Family history of Coronary Artery Disease,
esp. if premature.
Dornu Lebari
Classes of Angina
Jasdeep Singh Khangura
(3rd Year MBBS)
Classes of Angina
Classical/exertional angina pectoris
Decubitus angina
Variant (Prinzmetal’s) angina
Cardiac syndrome X
Unstable angina
Classical/ Exertional
Angina Pectoris
Provoked by physical exertion/ heavy meals/
cold weather
Aggravated by anger/ excitement
Pain fades quickly (minutes) upon resting
Can disappear with continued exertion
Predictable certain levels of exertion/ threshold
for pain development variable
Severity graded by Canadian Cardiovascular
Society (CCS)
Severity of Pain in Angina
(kindly excerpted without permission from Kumar and Clark, 4ed. Table 11.3,
page 631)
Decubitus Angina
Occurs lying down
Associated with impaired left ventricular
function/coronary artery disease
Includes nocturnal angina:
Wake patient from sleep
Provoked by vivid dreams
Critical coronary artery disease resulting in
vasospasm
Variant (Prinzmetal’s)
Angina
Angina that occurs w/o provocation e.g.
during rest
Coronary artery spasm
More frequent in women
ST elevation during pain
Provocation tests
hyperventilation testing
cold pressor testing
ergometrine challenge
Arrhythmias (ventricular tachycardia, heart
block) during ischaemic episodes
Cardiac Syndrome X
Includes patients who fulfil following criteria:
Patients with history of angina
positive exercise test
angiographically normal coronary arteries
Heterozygous group (functional abnormalities of
coronary microcirculation)
Prevalence: women>men
Good prognosis
Highly symptomatic  difficult to treat
Unstable Angina
 Includes:
Angina of recent onset (<1month)
Worsening angina
Angina at rest
 Lead to MI ( in 10% cases)
 Medical emergency
 Death in 1 year (5-15% of people)
 Admission of patient:
Bed rest
Aspirin (  incidence of death/ MI)
Heparin
Medical anti-anginal therapy
 Risk stratifying patients with unstable angina – (low/
intermediate/ high risk)
Risk Stratification in Patients with Unstable
Angina
(kindly excerpted without permission from Kumar and Clark, 4ed. Table 11.3,
page 691)
Management of Low Risk
Unstable Angina
Patient discharged
Assessed as elective outpatients
Intermediate Risk
Unstable Angina
Controversy/ grey area
Early intervention not influence long term
outcome
Therapies aimed at influencing procoagulant/ thrombogenic state – persist
several months following presentation
Management of High Risk
Unstable Angina
Prompt angiography
Re-vascularisation