Understanding Angina: Visual Explanation for Students

hi this is tom from zero finals comm in this video I'm going to be going through stable angina and you can find written notes on this topic at zero to finals comm forward slash stable angina or in the cardiology section of the zero finals medicine book so let's jump straight in angina is caused by a narrowing of the coronary arteries that supply the heart with blood and oxygen and this narrowing of the arteries reduces the blood flow to the myocardium which is the heart muscle so during times of high demand such as during exercise there's insufficient supply of blood to meet the demand of the heart muscle when somebody has angina and this causes the typical symptoms of angina which is like a constricting chest pain that may or may not radiate to the jaw or to the arms angina is described as stable when these symptoms of chest pain are always relieved by rest or by glycerol try nitrate or GTM spray it's described as unstable when the symptoms come on randomly while at rest and this is actually considered part of an acute coronary syndrome how do we investigate somebody who has these symptoms of stable angina well the gold standard investigation for assessing the coronary arteries in a patient who might have angina is to do a CT coronary angiography and what this involves is injecting a contrast and taking CT images timed with the heartbeat to give a really detailed view of the coronary arteries and this gives us a really good indication of whether there's any narrowing and those arteries and how good they are at allowing blood to be supplied to the heart outside of investigating the coronary arteries there's some baseline investigations it's worth doing on every patient presenting with these symptoms so first of all you do a physical examination and it's worth listening to the heart sounds for any possible structural or valvular heart disease looking for any signs of heart failure such as edema or crackles on the chest and measuring their weight and their waist circumference to look for risk factors for cardiovascular disease it's worth doing an ECG on every patient as a baseline and to look for any old ischemic changes doing a full blood count to look for anemia checking user knees which is useful prior to starting an ACE inhibitor and other medication checking their liver function tests which is useful prior to starting statins doing a lipid profile to look at their modifiable risk factors from a cholesterol point of view doing thyroid function tests which is useful for checking for hyper or hypothyroidism which can be linked to angina and doing a hba1c or a fasting glucose to look for diabetes so let's move on to management of stable angina and this management that I'm describing here is based on the 2018 nice clinical knowledge summaries on angina and the 2018 sign guidelines on the management of stable angina so it's worth before you treat anyone to have a look through those guidelines but for the sake of simplifying it and summarizing it for your exams I've gone through it here the first thing to do is to refer to cardiology and it's really important to do this urgently if they're having unstable angina you can do it a bit more routinely if they're stable advise them about the diagnosis the management and when to call an ambulance which we'll talk about in a bit treat them medically which we'll talk about in a second and there's also options for doing procedures and surgical interventions to treat the underlying stenosis of the coronary arteries so what's the medical management well there's three aims for medical management the first is the immediate relief of symptoms the second is to prevent the symptoms and the third is as secondary prevention for cardiovascular disease so immediate symptomatic relief is achieved using glycerol tri nitrate or GTN and we use a GTN spray that they can use as soon as the symptoms come on and what it does is it causes vasodilation and opens up those coronary arteries to allow more blood flow to come through what you would tell the patient is to take their GTN have some rest and then if the symptoms still persist after five minutes repeat the GTN dose then if they're still in pain five minutes after the repeat dose call an ambulance the second thing we talked about was the long term symptomatic relief and that's achieved with either a beta blocker such as bisoprolol five milligrams once a day or a calcium channel blocker such as amlodipine five milligrams once a day it's possible to use a combination of both of these if the symptoms are not controlled with one and there's a whole host of different options if they don't work such as long acting nitrates like Isis or Biden mononitrate ivabradine nikka Randall or ranolazine but these other options would probably be initiated by a cardiologist or a specialist then the third thing we talked about was secondary prevention and we can remember the secondary prevention as the forays firstly aspirin which would be 75 milligrams once a day at all the statin which would be 80 milligrams once a day an ACE inhibitor such as ramipril which would be titrated to the maximum tolerated dose and then the fourth a is usually a tunnel which basically clears us that they need a beta blocker but they're most likely to be on a beach blocker anyway for symptomatic relief so like I said there's also some surgical and procedural options the main procedure option is percutaneous coronary intervention with coronary angioplasty percutaneous coronary intervention or PCI is offered to patients with proximal or extensive disease on the CT angiography this involves putting a catheter into the patient's brachial or femoral artery and feeding that up into the coronary arteries under the guidance of an x-ray machine then they inject contrast which will show up on the x-ray and it's able to identify the area of stenosis in the coronary arteries then using this catheter they can inflate a balloon in that area of stenosis and stretch it out and once it stretched out they can actually insert a stent and leave that in there to maintain the patency of that coronary artery and really improve the blood flow to that area the alternative to this procedure is to do a surgical intervention called a coronary artery bypass graft which is commonly known as a cabbage and this is surgery that's offered to patients with really severe stenosis and what this involves is they make a cut right down the center of the chest along the sternum and this is called a midline sternotomy incision so the patient will be left with a midline sternotomy scar and then they take a graft vein from the patient's legs usually the great saphenous vein and they sew this graft vein on to the affected coronary artery in a way that bypasses the stenosis in that artery the recovery is quite a bit slower and there's quite a few more complications than doing PCI but it's very effective for severely stano's arteries finally just a bit of a tom tip when you're examining a patient that you think might have coronary artery disease always check their chest to look for a midline start to me scar which would indicate a previous cabbage and then check for scars along their inner calf's which could be where they've harvested a saphenous vein for that cabbage you can also check for scars on the brachial and the femoral arteries in the antecubital fossa and in the groin which might indicate they've had a previous pci procedure and this will basically impress your examiners and give you a really good clue about what that patient has been through in order to treat their coronary artery disease so thanks for watching I hope you found this video helpful if you did don't forget there's plenty of other resources on the zero to finals website including loads and loads of notes on various different topics that you might cover in medical school with specially made illustrations there's also a whole test section where you can find loads of questions to test your knowledge and see where you're up to in preparation for your exams there's also a blog where I share a lot of my ideas about a career in medicine and tips on how to have success as a doctor and if you want to help me out on YouTube you can always leave me a thumbs up give me a comment or even subscribe to the channel so that you can find out when the next videos are coming out so I'll see you again soon

Channel: Zero To Finals

Views: 237,962

Keywords: medical, education, medicine, doctor, stable angina, angina, coronary artery disease, atherosclerosis, statins, atorvastatin, medical student, atenolol, medical school, acute coronary syndrome, chest pain

Id: 7XkOuo5DwAU

Length: 9min 44sec (584 seconds)

Published: Thu Jan 24 2019