Angina

Question 1

What is angina?

Answer 1

Chest pain/discomfort that can occur when the heart muscle does not get enough blood.

Question 2

What is the usual cause of angina?

Answer 2

It usually implies that there is a narrowing of the coronary arteries and it tends to occur at times when the heart has to do more work (e.g. exercise or increased stress)

Question 3

Except for narrowing of the arteries, what are the other less likely causes of angina?

Answer 3

• arrhythmias
• arteritis
• valve disease (especially aortic stenosis)
• HOCM
• anaemia
• hypertensive heart disease

Question 4

What is stable angina?

Answer 4

Chest pain that is precipitated by predictable factors (e.g. strenuous activity)

Question 5

What is unstable angina?

Answer 5

Chest pain that occurs at any time and should be managed as a form of ACS

Question 6

Risk factors for angina?

Answer 6

Cardiovascular risk factors such as:

• obesity
• FHx of heart disease
• diabetes
• smoking
• hyperlipidaemia
• HTN
• physical inactivity
• cardiac abnormalities (especially outflow obstructions such as aortic stenosis and HOCM)

Question 7

What are the 3 angina pain features?

Answer 7

1. constricting discomfort in the central chest, neck, shoulders, arms and jaws
2. precipitated by physical exertion
3. relieved by rest or by GTN in about 5 minutes

Question 8

What is typical, atypical and non-angina chest pain?

Answer 8

Typical - all 3 angina features present
Atypical - 2 out of 3 angina features present
Non-angina pain - 1 or 0 angina features present

Question 9

Factors that makes stable angina less likely?

Answer 9

• continuous/prolonged chest pain
• unrelated to activity
• worse on inspiration
• associated symptoms (e.g. dizziness, palpitations, tingling or difficulty swallowing)

Question 10

Differentials for stable angina?

Answer 10

• ACS
• Printzmetal angina/ coronary artery vasospasm (occurs at rest, with most episodes happening early morning/circadian pattern)
• acute pericarditis (constant pain made worst lying flat, deep inspiration, swallowing, movement)
• pleuritic pain (e.g. pneumonia, PE. There may be purulent sputum or haemoptysis)
• acute cholecystis/gallstones
• musculoskeletal pain (worst on deep inspiration and rotation. Mostly local pain)

Question 11

Initial investigations for stable angina?

Answer 11

• 12 lead ECG: may see ischaemic changes (LBBB, pathological Q waves, ST segment and T wave abnormalities)
• FBC (anaemia), LFTs (before starting lipids), lipids/cholesterol, fasting glucose, TFTs (hyper can increase the heart’s load and hypo is associated with high cholesterol)
• troponin/cardiac enzymes: for permanent myocardial damage
• echo: assess cardiac function and the presence of HOCM or aortic valve disease

Question 12

Diagnosis of stable angina?

Answer 12

Mainly based on a clinical assessment alone or with diagnostic testing

Question 13

How urgent must suspected angina patients be referred to a Rapid Access Chest Pain Clinic?

Answer 13

Within 2 weeks for the diagnosis and assessment of their angina

Question 14

Management of angina

Answer 14

• beta block or calcium channel blocker (or both if not well controlled) as 1st line
• sublingual GTN for rapid relief
• aspirin (or clopidogrel for alternative)
• ACE inhibitor (if diabetic)
• statins

A 3rd anti-anginal drug (e.g. long acting nitrate) can be added when symptoms are not adequately controlled

High risk/not well controlled - coronary revascularisation

Question 15

Advice to give to patients with angina?

Answer 15

• lifestyle: reduce CV risk by smoking cessation, healthy diet/weight, exercise
• driving: stopped if symptoms occur at rest, resume when satisfactory control is achieved
• sexual activity: if patient can climb up and down the stairs briskly without symptoms, then sexual activity is unlikely to precipitate an episode. Could take GTN immediately before activity.