Download Angina - History

Angina - History
Chest Pain
- Site
 classically behind sternum
 sometimes left chest
 rarely right chest
 very rarely back
-
Radiation
 left arm commonest
 right arm sometimes
 both arms sometimes
 throat, chin
 back of neck occasionally
 epigastrium rarely
 back rarely
 sometimes pain reverses - starts in left wrist and radiates back to chest
 sometimes pain in left arm without chest pain
-
Character of pain
 gripping, squeezing, crushing, constricting "like vice/tight band"
 less convincing: ache, pressure, cramping, heaviness
 arm pain: lifelessness, deadness, uselessness
-
Duration of pain
 angina - lasts 5-10mins
 once causative factor removed
 never a few seconds, never hours
 If it lasts for hours - coronary spasm, MI (prinzmetal's angina, rest angina,
unstable angina)
Precipitating factors
- exertion (most important factor)
- mental stress, emotion, cold wind, heavy metal
Relieving factors
- stopping exertion
- glyceryl trinitrate - response in 1-2mins
Associated symptoms
- 'choking' in the throat (highly suggestive of angina)
- 'strangling' and 'suffocation' (also highly suggestive)
- breathlessness (transient LVF)
- dizziness (could be anxiety
-
syncope (rare)
belching at end of attack
Examination
May be no abnormal physical signs
-
Signs of arteriosclerosis
 retina-arteriolar narrowing and a-v nipping
 systolic murmur over carotid artery
 hypertension
 thickened radial artery
 arcus senilis (premature arteriosclerosis)
 xanthelasma (hyperlipidaemia)
 tortuous brachial artery
 systolic murmur over abdominal aorta
 reduced femoral pulse with murmur over vessel
 absent foot pulses
-
Signs of hyperlipidaemia
 xanthelasma
 arcus senilis
 xanthomata (tendons, skin extensor surfaces)
Differential diagnosis
Functional pain (left mammary or inframammary stabbing, or continuous ache, lasts
seconds, hours, days. Unrelated to exertion, anxiety symptoms, local tenderness in chest
wall)
Pleuritic pain (localised to one side. Sharp, stabbing, knife-like. Worse on inspiration
and coughing. Associated phlegm -purulent (infection), -blood (embolism). Pleural rub
on auscultation)
Hiatus hernia (retrosternal burning pain. Worse on bending, lying down, after a heavy
meal. Associated with heart burn)
Peptic ulcer (epigastric and lower sternal pain, deep gnawing pain, related to meals,
relieved by alkalis, may be associated with vomiting which relieves the pain, epigastric
tenderness)
Pericarditis (retrosternal pain, worse on lying, better on standing or sitting up, worse
with inspiration and coughing. May hear pericardial rub)
Cervical spondylosis (upper chest pain, involves shoulders and arms, unrelated to
exertion. Worse with movements of neck. Often crepitus on moving head)
Investigations
ECG - during attacks - ST depression or symmetrical T wave inversion.
T wave inversion in V1 - V3 indicates critical left anterior descending coronary artery
stenosis.
May show old MI or left ventricular hypertrophy
Exercise ECG
contraindicated in unstable angina, recent MI (7days), severe aortic stenosis, severe
pulmonary hypertension, significant rhythm disturbances
relative contraindications: infirmity and ataxia
Positive test - 1mm of J point depression (junction of ST and T wave)
(False +ve's : hyperventilation, digoxin and other anti-arrhythmics, hypokalaemia,
hypertension, valvular heart disease, left ventricular hypertrophy and pre-excitation
syndromes)
terminate test if BP falls, VT or if patient becomes pale (peripheral circulatory collapse)
relative contraindications for termination: ST depression >4mm, incoordination,
paroxysmal rhythm disturbances (other than VT)
ECHOCARDIOGRAPHY
Assess ventricular function and localise areas of ventricular wall involvement.
In angina (no infarction) may be normal
Exercise or pharmacological stress echo can detect 'hibernating' myocardium i.e. areas
with decreased blood flow.
NUCLEAR IMAGING
Assess myocardial structure and function.
Thallium is injected during exercise - serial x-rays
'Cold spot' that recovers on rest = angina
Fixed cold spot = infarction
CORONARY ANGIOGRAPHY + CARDIAC CATHETERISATION
Determine exact coronary anatomy and decide further management
Reserved for
- angina resistant to medical therapy
- strongly +ve exercise test (indicates poor prognosis
- unstable angina
- persisting angina after MI
Mortality from procedure 1 in 1000
Complications : Haemorrhage at site of arterial puncture
Emboli - leading to MI
Stroke
Arrhythmias
Coronary artery dissection
Infection
Treatment
General measures
- explain and reassure
- evaluate risk factors (stop smoking, lose weight, diet)
- avoid cold weather, emotion
- encourage exercise within limits
Drugs
- Aspirin
- consider Statins
- GTN for acute attacks
-
Prophylactic treatment if regular attacks:
ß-blockers (reduce sympathetic tone - negatively inotropic, reduces myocardial
contractility/ - negatively chronotropic, decreases heart rate. Reduced Oxygen demand,
improve perfusion - longer diastole, more time for coronary blood to flow)
contra-indications : asthma, peripheral vascular disease with skin ulceration. 2nd or 3rd
degree heart block.
Atenolol 50-100mg/day
Metoprolol 25-50mg TDS
Nitrates: peripheral vasodilation, increases venous return and decreases ventricular
volume. Decreased distension of heart wall and decreased Oxygen demand.
Sublingual GTN acts for ~30mins
ISMN 10-60mg BD
slow release ISMN 60-120mg OD
adverse effects: headaches, flushing, hypotension, rarely fainting
Calcium channel blockers
- peripheral arteriolar dilatation
- reduced afterload
Dihydropyridines (nifedipine) can cause reflex tachycardia, always give with ß-blocker
Slow release Nifedipine 10-40mg BD
Diltiazem has -ve inotropic and chronotropic effects, careful monitoring if on ß-blockers
Verapamil if ß-blockers contraindicated
Contraindicated in heart block and heart failure
Side-effects - constipation
dihydropyridines - headaches, flushing, dizziness, gravitational oedema
Potassium Channel Activators
- arterial and venous dilation
Nicorandil 10-30mg BD
side effects : headache, flushing, nausea, vomiting, dizziness
Unstable Angina