Angina

Question 1

What is angina?

Answer 1

It is a condition in which narrowing of the coronary arteries results in reduced blood flow to the myocardium

Question 2

What are the two classifications of angina?

Answer 2

Stable

Unstable

Question 3

What is stable angina?

Answer 3

This is when clinical features are relieved by rest or GTN

Question 4

What is unstable angina?

Answer 4

This is when clinical features are stimulated at rest

Question 5

What is unstable angina a classification of?

Answer 5

Acute coronary syndrome

Question 6

What is the main clinical feature of angina?

Answer 6

Chest pain

This pain may radiate to the jaw or arms

Question 7

What three investigations are used to diagnose angina?

Answer 7

Bloods

CT angiography

ECG scan

Question 8

What six blood tests are used to diagnose angina?

Answer 8

FBC

U&Es

LFTs

Lipid profile

TFTs

HbA1C & Glucose

Question 9

What is the gold standard investigation used to diagnose angina?

Answer 9

CT coronary angiography

Question 10

What is a CT angiography?

Answer 10

A CT coronary angiograph involves inserting a catheter into the patient’s brachial or femoral artery and feeding that up to the coronary arteries under x-ray guidance

There is then contrast injected into the coronary arteries and CT images are taken in time with the heartbeat

Question 11

In what four ways do we manage stable angina?

Answer 11

RAMP

Refer to cardiology

Advise them about the diagnosis, management and when to call an ambulance

Medication

Procedural/Surgical intervention

Question 12

What do we administer to provide immediate symptomatic relief of angina?

Answer 12

GNT spray (sublingual)

Question 13

What is the function of GNT spray?

Answer 13

It causes vasodilation of the coronary arteries

Question 14

What two medications are administered to provide long term symptomatic relief?

Answer 14

Betablocker

AND/OR

Calcium Channel Blocker

Question 15

What is the first line long term pharmacological management option?

Answer 15

Betablocker

Question 16

Name a beta-blocker used to manage angina. What dose is prescribed?

Answer 16

Bisoprolol

5mg once daily

Question 17

What two calcium channel blockers are used to manage angina - when prescribed as monotherapy?

Answer 17

Verapamil

Diltiazem

Question 18

What should we do if monotherapy with either a beta blocker or calcium channel blocker is insufficient in controlling angina symptoms?

Answer 18

We increase to the maximum dose

THEN

We administer in combination (beta blocker and calcium channel blocker)

Question 19

What calcium channel blocker should be administered to manage angina - when prescribed in combination with a beta-blocker? Which is contraindicated? Why?

Answer 19

Long-acting dihydropyridine calcium-channel blocker (amlodipine, nifedipine)

Verapamil - There is a risk of complete heart block, bradycardia and asystole

Question 20

What four drugs are administered if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker?

Answer 20

Long acting nitrate

Ivabradine

Nicorandil

Ranolazine

Question 21

What two long acting nitrates are used to manage angina?

Answer 21

Isosorbide

Mononitrate

Question 22

What complication is associated with long acting nitrates? How do we reduce this risk?

Answer 22

Tolerance

We advise an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours

Question 23

What is the mechanism of action of nicorandil?

Answer 23

It is a potassium channel activator drug, allowing entry of potassium into cardiac myocytes

This results in relaxation of vascular smooth muscle and dilatation of the systemic venous circulation

Question 24

What is the mechanism of action of ivabradine?

Answer 24

It is a potassium channel inhibitor drug, which selectively acts on the sinoatrial node

This slows down the diastolic depolarisation of the sinoatrial node – reducing heart rate and therefore myocardial oxygen demand

Question 25

What is the mechanism of action of ranolazine?

Answer 25

It is a sodium channel inhibitor drug, which leads to a reduction in intracellular calcium levels This reduces the tension in the heart muscle, lowering its oxygen demand

Question 26

What four drugs are administered to angina patients to prevent CVD?

Answer 26

4As Aspirin Atorvastatin ACEI Already on a beta-blocker

Question 27

What dose of aspirin is administered to control angina?

Answer 27

75mg once daily

Question 28

What dose of atorvastatin is administered to control angina?

Answer 28

80mg once daily

Question 29

What two surgical procedures are used to manage angina?

Answer 29

Percutaneous coronary intervention (PCI) with coronary angioplasty Coronary artery bypass graft (CABG)

Question 30

What is PCI with coronary angioplasty?

Answer 30

It involves dilating a blood vessel with a balloon and/or inserting a stent

Question 31

Who is offered a PCI with coronary angiography?

Answer 31

Those with proximal or extensive disease on CT angiography

Question 32

What is CABG?

Answer 32

It involves opening the chest along the sternum, taking a graft vein from the patients leg and sewing it onto the affected coronary artery to bypass the stenosis

Question 33

What vein is often used as a graft in CABG?

Answer 33

Great saphenous vein

Question 34

What scar is often left after CABG?

Answer 34

Midline sternotomy scar

Question 35

Who is offered CABG?

Answer 35

Those with severe stenosis

Question 36

What anticoagulant is administered during CABG?

Answer 36

Heparin

Question 37

How do we reverse the effects of heparin?

Answer 37

Protamine sulphate

Question 38

What procedure has a higher complication rate and slower recovery time - PCI or CABG?

Answer 38

CABG