Lets Grass On Cardio Ii

A 45 years old man presented with chest pain consistent with Ischemic Heart Disease and confirmed by ECG findings as Angina.
The patient has a 5 year history of exertional dyspnea, lethargy, and fatigue and gradual signs and symptoms of Right Sided Heart Failure and was diagnosed with Idiopathic Pulmonary Hypertension as a cause one year ago after extensive workup.

The patient has no history nor risk factors for atherosclerotic disease.

If the angina was in the right side, what would be the possible cause?

If the angina was in the left side, what would be the possible cause?

Angina on the left side, it could be due to insufficient blood supply to the coronaries .
pulmonary hypertension will result in decrease blood supply coming from the lung to the left atrium via pulmonary veins so the blood coming to the left side of heart will be decreased leading to less blood passing through the aorta and then to coronary.

Angina to the right side, I can not find a specific cause

if the above is right then both coronaries share the same origin from aorta so what will cause angina in the left coronary will cause the same on the right ?!!!

another thought, could it be due to vasospasm?

please do correct me

if im wrong

regards

Dear Farah thank you for the reply,

pulmonary hypertension usually causes angina due to inability to increase cardiac output in cases of exertion, the cause of the right sided angina is mostly due to the increased oxygen demand [ventricular hypertrophy] and due to subendocardial hypoperfusion caused by increased right ventricular wall stress [increased intraventricular pressure].

now, you are on the right path, its the pulmonary hypertension that is causing the angina.

Now what is the mechanism behind the left side?

what is the mechanism behind the left side?

blood supply to the left side of heart will decrease because of the pulmonary hypertension and in turn this will lead to decrease of cardiac output and this will stimulate the neuronal body response to increase sympathetic tone to increase systemic resistance .now the left heart will have to contract against resistance and this will cause the angina on the left side .
i.e. there is already decrease in stroke volume then increase in systemic vascular resistance and this will decrease the blood flow to the aorta and then to coronaries so this will lead to the angina.

Thanx Dr Farah,

well, on the right side we have ventricular hypertrophy----so increased O2 demand
+
increased intraventricular pressure ---- so increased stress on the subendocardium ---- so less perfusion
+
failure to increase C O

on the left side we dont have increased demand nor increased intraventricular pressure and no stress on the ventricular wall.

when cardiac output is so low, it will cause syncope or orthostatic hypotension. the body will increase the sympathetic tone to compensate but i dont think it will reach a point of high resistance. However, This patient doesnt have this.

Remember that coronoray arteries depend on the Diastolic pressure rather than the systolic.

HINT: this patient can have hoarsness of voice.

Happy Eid

ok let me start with your hint ,

the dilated left pulmonary artery will compress the left recurrent laryngeal nerve causing the hoarsness of voice .

so could the angina on the left be due to external compression on the aorta or the coronary by the dilated pulmonary vessels!!!!

bcmf/hmm.gif

Exellent Job Dr Farah, its is the right answer.

Its compression of the left coronary by the dilated Main Pulmonary Artery.

is that cool or what

Cheers!