Angina

Question 1

Investigation of suspected angina?

Answer 1

Should be performed via referral to rapid access chest pain clinic- may involve cardiac MRI, exercise ECG, PCI

Question 2

First-line treatment stable angina?

Answer 2

Beta blocker or rate-limiting calcium channel blocker e.g. diltiazem, verapamil

Question 3

How do you know when a patient is adequately beta-blocked?

Answer 3

Resting heart rate <65 bpm

Post-exercise heart rate <95 bpm

Question 4

If monotherapy with first-line treatment is ineffective?

Answer 4

Switch to other first-line treatment

Can also add dihydropyridine CCB (e.g. amlodipine) to beta blocker

Question 5

Rate-limiting CCBs are contraindicated in…?

Answer 5

Heart failure
Bradycardia
Heart block
Cardiac outflow obstruction e.g. aortic stenosis, obstructive HOCM

Question 6

Dihydropyridine CCBs are contraindicated in…?

Answer 6

Uncontrolled heart failure
Hypotension
Cardiac outflow obstruction

Question 7

Alternative regular treatments for stable angina? (4)

Answer 7

Long-acting nitrates e.g. ISMO
Potassium channel activator e.g. nicorandil
Ivabradine
Ranolazine

Question 8

Side-effects of nitrates? (4)

Answer 8

Headache, dizziness, postural hypotension, reflex tachycardia (which can worsen angina)

Question 9

How can tolerance to nitrates be avoided?

Answer 9

Ensuring ISMO-free period e.g. removing patches, giving second dose of ISMO tablets in early evening (asymmetric dosing intervals)

Question 10

Nitrates are contraindicated in..? (5)

Answer 10

Acute MI
HOCM
Aortic/mitral stenosis
Closed-angle glaucoma
Hypotension

Question 11

How should response to treatment be monitored?

Answer 11

2-4 weeks after changing/starting drug; titrate dose against symptoms up to the maximum tolerated/licensed

Question 12

Drug treatment for secondary prevention? (4)

Answer 12

Antiplatelet (usually aspirin 75mg)
Statin- usually atorvastatin 80mg
ACE inhibitor
Adequate management of hypertension