ACS & Stable Angina

Question 1

What is stable angina and how does it differ from unstable angina?

Answer 1

Stable angina is the reversible imbalance between supply/demand of oxygen.
Its main difference with UA is that its onset is during exercise or when stress is induced (spontaneous chest chain = UA)
Symptoms must be >2months and with no change to be stable angina.
It is the most common form of ischaemic heart disease

Question 2

Angina can be caused by atherosclerosis, as well as what?

Answer 2

1. Coronary vasospasms
2. Systemic Disease
3. Microvascular dysfunctions
4. Left ventricular hypertrophy
5. High BP/tachycardia

Question 3

What is stenosis & what does it do in stable angina?

Answer 3

Stenosis is the narrowing of arteries due to plaque, which eventually rupture.
This leads to less coronary blood flow during exercise/stress.

Question 4

What are the 3 main symptoms of stable angina?

Answer 4

1. Left/central chest pain
2. Provoked by exercise/stress
3. Pain only goes with GTN spray

Question 5

What are some examples of differential diagnosis of stable angina?

Answer 5

1. Pneumonia
2. GORD
3. Pericarditis
4. Pulmonary embolism
5. Musco-skeletal pain

Question 6

Where would you refer a patient who has stable and unstable angina?

Answer 6

Stable angina: rapid chest pain clinic

Unstable angina: A&E

Question 7

What are some non-invasive and invasive tests performed to diagnose stable angina?

Answer 7

Non-invasive:

1. Anatomical: CT coronary angiography
2. Stress tests: MRI perfusion scan, exercise ECG, stress echocardiography

Invasive:
1. Coronary angiography

Question 8

What is the treatment/management of stable angina?

Answer 8

1. Symptom control: restoring O2 supply/demand with GTN spray
2. Secondary prevention: lifestyle changes + drugs (antiplatelets/statins)
3. Revascularisation: stenting, or bypass surgery

Question 9

What is GTN metabolised into & what are 2 potential side effects?

Answer 9

It is metabolised into NO.

Side effects can include dizziness and hypotension.

Question 10

What are the two 1st line treatment drugs for stable angina?

Answer 10

1. B-blockers - bisoprolol 10mg OD
   - They decrease BP/HR & prolong filling time
2. Calcium channel blockers (CCB’s) - diltiazem
   - Rate limiting CCB are like b-blockers
   - Non-rate limiting induces vasodilation

Question 11

What are the four 2nd line treatment drugs for stable angina?

Answer 11

1. Long acting nitrates
   - Causing vasodilation
2. K+ channel openers (nicorandil)
3. Inhibiting Na+ current (ranolazine)
4. Ivabradine

Question 12

What is CABG surgery?

Answer 12

Coronary artery bypass graft.

Blood vessels are plugged into the coronary artery vasculature to bypass a blockage.