Angina Flashcards
What are the classification of Angina?
- Classical Angina
- Unstable angina
- Refractory Angina
- Vasospastic or Variant angina
- Microvascular Angina
What is classical angina?
- Characterised by chest pain described as heavy, tight or gripping.
- Typically, pain is central/retrosternal and may radiate to jaw and/or arms.
- Pain tends to occur with exercise or emotional stress or when walking up close in cold weather and eases rapidly with rest
What is Unstable Angina?
- Refers to angina of recent onset (<24h) or deterioration in previous stable angina with symptom frequently occurring at rest.
- Acute coronary syndrome
What is Refractory Angina?
Patient with severe coronary disease in whom revascularization is not possible and angina not controlled by medical therapy
NICE defines angina as:
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- Precipitated by physical exertion
- Relieved by rest or GTN in about 5 minutes
How do you label patient based on the NICE definition of Angina?
- Patients with all 3 features have typical angina
- Patients with 2 of the above features have atypical angina
- Patients with 1 or none of the above features have non-anginal chest pain
What do you look for on examaination for Angina?
- S4 sound may be heard
- Sign suggesting anaemia, thyrotoxicosis or hyperlipidaemia (lipid arcus, xanthelasma, tendon xanthoma)
What are diagnostic investigations of Angina?
1st Line: CT angiography
2nd Line: Non-invasive functional testing
- Use MPS with SPECT or Stress Echocardiography
- First pass contrast-enhanced magnetic resonance perfusion
- MRI for stress induced wall motion abnormalities
3rd Line: Invasive Coronary Angiography
What are other investigations of Angina?
- Blood test
- TFTs
- Fasting Glucose, HbA1c
- Fasting Lipid Progile
- Glomerular Filtration
- Troponin if unstable
- 12 lead ECG
- Chest XR
- Echocardiography
- Diastolic Function, alternative causes to chest pain
What agents are used for non-invasive functional testing?
- Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT
- Adenosine or dipyridamole for first pass contract MR perfusion
What is lifestyle advice for Angina?
- Exercise
- Smoking cessation
- Diet
- Weight control
- Psychological support and offer interventions if necessary
How is symptomatic pain relief provided in Angina?
Offer a short-acting nitrate to prevent and treat episodes of angina
What are the general guidelines of Angina treatment?
- One or Two anti-anginal drugs as necessary plus
- Drugs for secondary prevention of cardiovascular disease.
What is the optimal drug treatment of Angina?
First line: Beta-blocker or Calcium Channel Blocker. Switch medication or use a combination of both if uncontrolled
If drugs are contraindicated or not tolerated, consider mono therapy or adding one drug using one of the following
- Long-acting nitrate (isorbide mononitrate)
- Ivabradine
- Nicorandil
- Ranolazine
What is done for patients whose angina isn’t controlled by two anti-anginas drugs?
- Needs referral to cardiology
- Third Anti-anginal drug whilst awaiting specialist review
When should third anti-anginas drugs be prescribed?
-The person’s symptoms are not satisfactorily controlled with two anti-anginal drugs and -The person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable.
What is the secondary prevention of Angina?
- Consider Antiplatelet treatment in all people with stable angina taking into account the person’s risk of bleeding and co-morbidities. For most people this is low dose aspirin
- Consider treatment with an ACE inhibitor for people with stable angina and Diabetes mellitus
- Offer a Statin and Antihypertensive treatment
When should revascularization be initiated?
- Consider in people whose stable angina is not controlled with optimal medical treatment.
- Offer coronary angiography to guide treatment strategy
- Treatment options:
- Coronary artery bypass grafting
- Percutaneous coronary intervention.
When is CABG better?
CABG is better for patient who have multivessel disease that isn’t controlled with medical treatment and have:
- Diabetes or
- Are over 65 or
- Have anatomically complex three-vessel disease, with or without involvement of left main stem
What should all patient with an NSTEMI receive?
- Aspirin 300mg
- Ticagrelor or Prasugrel
- Nitrates or Morphine to relieve chest pain if required
What is antithrombin treatment for patients with NSTEMI?
- Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours.
- If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l, unfractionated heparin should be given.
What should be given to patients who have intermediate or higher risk of adverse cardiovascular events and scheduled for angiography?
Intravenous glycoprotein IIb/IIIa receptor antagonists
- Eptifibatide
- Tirofiban
When should coronary angiography be done in patients with NSTEMI?
Within 96 hours of first admission to hospital for patients with a predicted 6 month mortality above 3%
What should be given to patients who have had a TIA to prevent further occlusive events?
1st line: Clopidogrel
2nd line: Aspirin & Dipyridamole
Both Lifelong
What should be given to patients who have had an Ischaemic Stroke to prevent further occlusive events?
1st line: Clopidogrel
2nd line: Aspirin & Dipyridamole
Both Lifelong
What should be given to patient who have had a diagnosis of peripheral arterial disease?
1st line: Clopidogrel
2nd line: Aspirin
Both Lifelong
What should be given to patient who have had PCI?
Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
If aspirin contraindicated, clopidogrel (lifelong)
What should be given to patients with Acute Coronary Syndrome?
1st line: Aspirin (lifelong) & ticagrelor (12 months)
If aspirin contraindicated, clopidogrel (lifelong)
