Angina Flashcards
What is angina?
It is a condition in which narrowing of the coronary arteries results in reduced blood flow to the myocardium
What are the two classifications of angina?
Stable
Unstable
What is stable angina?
This is when clinical features are relieved by rest or GTN
What is unstable angina?
This is when clinical features are stimulated at rest
What is unstable angina a classification of?
Acute coronary syndrome
What is the main clinical feature of angina?
Chest pain
This pain may radiate to the jaw or arms
What three investigations are used to diagnose angina?
Bloods
CT angiography
ECG scan
What six blood tests are used to diagnose angina?
FBC
U&Es
LFTs
Lipid profile
TFTs
HbA1C & Glucose
What is the gold standard investigation used to diagnose angina?
CT coronary angiography
What is a CT angiography?
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
In what four ways do we manage stable angina?
RAMP
Refer to cardiology
Advise them about the diagnosis, management and when to call an ambulance
Medication
Procedural/Surgical intervention
What do we administer to provide immediate symptomatic relief of angina?
GNT spray (sublingual)
What is the function of GNT spray?
It causes vasodilation of the coronary arteries
What two medications are administered to provide long term symptomatic relief?
Betablocker
AND/OR
Calcium Channel Blocker
What is the first line long term pharmacological management option?
Betablocker
Name a beta-blocker used to manage angina. What dose is prescribed?
Bisoprolol
5mg once daily
What two calcium channel blockers are used to manage angina - when prescribed as monotherapy?
Verapamil
Diltiazem
What should we do if monotherapy with either a beta blocker or calcium channel blocker is insufficient in controlling angina symptoms?
We increase to the maximum dose
THEN
We administer in combination (beta blocker and calcium channel blocker)
What calcium channel blocker should be administered to manage angina - when prescribed in combination with a beta-blocker? Which is contraindicated? Why?
Long-acting dihydropyridine calcium-channel blocker (amlodipine, nifedipine)
Verapamil - There is a risk of complete heart block, bradycardia and asystole
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?
Long acting nitrate
Ivabradine
Nicorandil
Ranolazine
What two long acting nitrates are used to manage angina?
Isosorbide
Mononitrate
What complication is associated with long acting nitrates? How do we reduce this risk?
Tolerance
We advise an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours
What is the mechanism of action of nicorandil?
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
What is the mechanism of action of ivabradine?
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
What is the mechanism of action of ranolazine?
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
What four drugs are administered to angina patients to prevent CVD?
4As
Aspirin
Atorvastatin
ACEI
Already on a beta-blocker
What dose of aspirin is administered to control angina?
75mg once daily
What dose of atorvastatin is administered to control angina?
80mg once daily
What two surgical procedures are used to manage angina?
Percutaneous coronary intervention (PCI) with coronary angioplasty
Coronary artery bypass graft (CABG)
What is PCI with coronary angioplasty?
It involves dilating a blood vessel with a balloon and/or inserting a stent
Who is offered a PCI with coronary angiography?
Those with proximal or extensive disease on CT angiography
What is CABG?
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
What vein is often used as a graft in CABG?
Great saphenous vein
What scar is often left after CABG?
Midline sternotomy scar
Who is offered CABG?
Those with severe stenosis
What anticoagulant is administered during CABG?
Heparin
How do we reverse the effects of heparin?
Protamine sulphate
What procedure has a higher complication rate and slower recovery time - PCI or CABG?
CABG
