CARDIOVASCULAR

IHD
Stable Angina Pectoris
Defn: Due to fixed atherosclerotic lesions that narrow the major coronary arteries. Coronary ischaemia is due to
an imbalance between bloody supply and O2 demand, leading to inadequate perfusion. Stable angina occurs
when O2 demand exceeds available bloody supply.

Major RFs:
 HTN (most common RF)
 DM (worst RF)
 Hyperlipidaemia (elevated LDL)
 Low levels of HDL
 Smoking
 Age (men >45yo, women >55yo)
 Fam Hx of premature CAD or MI in 1st degree relative (men <55yo, women <65yo)
Minor RFs:
 Obesity
 Sedentary lifestyle
 Stress
 Excess EtoH use

Prognostic Indicators:
 L ventricular function (ejection fraction [EF])
o Normal > 50%
o If <50%, associated with increased mortality
 Vessel(s) involved (severity/extent of ischaemia)
o L main coronary artery – poor prognosis (it supplies ~2/3 of heart)
o 2 or 3 vessel CAD – worse prognosis

Clinical Features
1. Chest pain or substernal pressure sensation (typically; substernal, worse with exertion, and better with
rest or GTN)
a. Lasts less than 10-15mins (usually 1-5mins)
b. Frightening chest discomfort, usually described as heaviness, pressure, squeezing, tightness;
rarely described as sharp or stabbing pain
c. Pain is often gradual in onset
2. Brought on by factors that increase myocardial O2 demand, such as exertion or emotion
3. Relieved with rest/GTN
4. Pain does NOT change with breathing or with body position, NO chest well tenderness (if any of these
present then pain is not likely due to ischaemia)

Diagnosis
1. Physical Ex in most pts is normal
2. Resting ECG (best initial test for all forms of chest pain)
a. Usually normal in pts with stable angina
b. Pathological Q waves are consistent with a prior MI
c. If ST segment or T wave abnormalities are present during an episode of chest pain, then treat as
USA
3. Stress test – useful for pts with an intermediate pretest probability of CAD based upon age, gender and
symptoms
a. Stress ECG
 Highest sensitivity if pts have normal resting ECG, such that changes can be noted
 Test involves recording ECG before, during, and after exercise on a treadmill
  75% sensitive if pts are able to exercise sufficiently to increase HR to 85% of maximum
predicted value for age (Maximum HR = 220 – age)
 Detection of ischaemia on an ECG stress test is based on presence of ST segment
depression (exercise-induced ischaemia results in subendocardial ischaemia, producing
ST depression)
 Other +ve findings include onset of HF or ventricular arrhythmia during exercise of
hypoTN
 Pts with a +ve result should undergo cardiac catheterization
b. Stress ECHO
 Performed before and immediately after exercise
 Exercise-induced ischaemia is evidenced by wall motion abnormalities (eg. akinesis or
dyskinesis) not present at rest
 Compared to stress ECG; more sensitive in detecting ischaemia, can assess LV size and
function, can diagnose valvular disease, and can be used to identify CAD in the
presence of pre-existing ECG abnormalities
 Pts with +ve result should undergo cardiac catheterization
c. Information gained from a stress test can be enhanced by stress myocardial perfusion imaging
after IV administration of a radioisotope such as thallium 201 during exercise.
 Viable myocardial cells extract the radioisotope from the blood. No radioisotope uptake
means no blood flow to an area of the myocardium
 Important to determine whether the ischaemia is reversible (whether areas of
hypoperfusion are perfused over time as blood flow eventually equalizes).

Syndrome X