Angina Flashcards
Why does angina occur?
Narrowing of the coronary arteries reduces flow to myocardium (heart muscle). During times of high demand (exercise) there is insufficient blood supply to meet demand
Typical symptoms?
Constricting chest pain - may radiate to jaw or neck
What’s stable angina?
When symptoms relieved by rest OR glyceryl trinitrate (GTN)
What’s unstable angina?
When symptoms come on at rest
Which angina is a form of ACS?
Unstable angina
Gold standard diagnostic investigation?
CT coronary angiography
Baseline investigations?
- PE (HS, signs of HF, BMI)
- ECG
- FBC (anaemia can cause angina)
- U&Es
- TFTs (hypo/hyperthyroid)
- LFTs
- Lipid profile/cholesterol
- HbA1c + fasting glucose (for diabetes)
When would you tend to measure U&Es in angina patients?
Prior to starting ACEi and other meds affecting kidney
When would you measure LFTs for angina patients?
Prior to starting statins
4 Principles of management?
RAMP: R - Refer to cardiology (if unstable) A - Advise them on diagnosis, management + when to call 999 M - Medical treatment P - Procedural or surgical interventions
3 aims of medical management?
1) immediate symptomatic relief
2) long term symptomatic relief
3) Secondary prevention of CVS disease
Immediate symptomatic relief?
Glyceryl trinitrate (GTN) PRN:
- causes vasodilation
- take when symptoms start + repeat >5 mins if required: if there is still pain 5 mins after repeat dose CALL 999
Long term symptomatic relief (anti-anginals)?
1) Beta-blocker (bisoprolol 5mg OD)
2) CCB (amlodipine 5mg OD) - ADD if not controlled
Specialist long term symptomatic relief (anti-anginals)?
Long acting nitrates:
- isosorbide mononitrate
- ivabradine
- nicorandil
- ranolazine
Secondary prevention?
4 A's: Aspirin (75mg OD) Atorvastatin (80mg OD) ACE inhibitor Already on a beta-blocker for symptomatic relief (add if on CCB?)
When would you consider procedural/surgical intervention?
After 2 or more anti-anginals fail
What would warrant a patient having a Percutanous Coronary Intervention (PCI)?
if CT coronary angiogram shows ‘PROXIMAL’ or ‘EXTENSIVE’ disease
What would warrant a patient having a CABG?
If CT coronary angiogram shows severe stenosis
CABG scar?
Midline sternotomy scar
Which graft vein is usually taken from the leg to bypass stenosis?
Great saphenous vein
Which veins are catheters for PCI inserted into?
Brachial & femoral
What patients would you opt for a CABG > PCI?
Diabetics
valvular disease
Which CCBs should you use for:
a) monotherapy
b) alongside beta-blocker
a) verapamil OR diltiazem (rate-limiting)
b) modified-release nifedipine, amlodipine (long acting)
Which drugs in combination may cause heart block?
beta-blocker w/ verapamil OR diltiazem (rate-limiting)
Steps to take if poor response?
1) increase long-term relief option to max tolerated dose (beta-blocker or CCB)
2) still poor response - add other long-term relief
3) if doesn’t tolerate/CI for CCB/beta-blocker:
- long-acting nitrate
- ivabradine
- nicorandil
- ranolazinee
4) if taking CCB + beta-blocker, consider 3rd drug whilst awaiting assessment for PCI/CABG
Which medication commonly results in increased tolerance/reduced therapeutic effect?
Nitrates - commonly standard release isosorbide mononitrate
Common SE of nicorandil?
GI ulcers (anywhere)! Diverticulitis patients have high risk of bowel perforation
Medication that causes sexual dysfunction?
Beta-blockers
Which treatment option for stable angina doesn’t improve survival?
PCI - does improve for ACS patients.
beta-blockers - improve survival if previous MI/HF
