Angina

Question 1

What is Ischaemic Heart Disease?

Answer 1

Spectrum of heart disease resulting from atherosclerosis in the coronary arteries.

Question 2

What is Angina?

Answer 2

A clinical syndrome that occurs when there is imbalance between supply and demand of Oxygen/nutrients to the myocardium, resulting in myocardial ischaemia.

Question 3

Aetiology of Angina (2).

Answer 3

1. Atherosclerosis.
2. Aortic Stenosis.

Question 4

Pathophysiology of Stable Angina.

Answer 4

Atherosclerosis - gradual enlargement of a stable plaque leading to luminal stenosis (Poiseuille’s Law).

Question 5

Clinical Presentation of Angina (3).

Answer 5

1. Constricting Pain in Chest/Neck/Arm/Jaw.
2. Triggered by Exertion.
3. Alleviated by Rest/GTN within Minutes.

Question 6

What is Atypical Angina?

Answer 6

2 out of the 3 features.

Question 7

Gold-Standard Investigation of Stable Angina.

Answer 7

Gold-Standard : CT Coronary Angiography.

Question 8

Management of Stable Angina - General (4).

Answer 8

RAMP :
1. R - Refer to Cardiology.
2. A - Advise about Diagnosis, Management and Safety Netting.
3. M - Medical Management.
4. P - Procedural/Surgical Management.

Question 9

Aims of Medical Management (3).

Answer 9

1. Immediate Symptomatic Relief.
2. Long-Term Symptomatic Relief.
3. Secondary Prevention of Cardiovascular Disease.

Question 10

Immediate Medical Management.

Answer 10

GTN - Glyceryl Trinitrate Sublingual Spray causes vasodilation. Repeat after 5 minutes and call ambulance if pain persists after 2 GTN sprays.

Question 11

Long-Term Symptomatic Medical Management (3).

Answer 11

1. B-Blocker or Rate-Limiting CCB.
2. Combination of 1*.
3. Other : Isosorbide Mononitrate (Long-Acting Nitrate); Ivabradine; Nicorandil; Ranolazine.

Question 12

Combination Therapy in Long-Term Symptomatic Management (2).

Answer 12

1. Use a long-acting DHP CCB e.g. Modified-Release Nifedipine if using with a B-Blocker.
2. Don’t prescribe concurrent B-blocker with Verapamil - risk of complete heart block.

Question 13

How should Isosorbide Mononitrate be taken?

Answer 13

Asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance.

Question 14

Secondary Prevention of Cardiovascular Disease (3).

Answer 14

1. Aspirin 75mg Once Daily.
2. Atorvastatin 80mg Once Daily.
3. ACE Inhibitor.

Question 15

Procedural/Surgical Interventions in Stable Angina (2).

Answer 15

1. PCI with Coronary Angioplasty.
2. CABG - Coronary Artery Bypass Graft.

Question 16

When is CABG offered?

Answer 16

Severe stenosis.

Question 17

What does CABG involve?

Answer 17

Midline sternotomy and harvesting from great saphenous vein.

Question 18

Adverse Effect of Nicorandil.

Answer 18

Ulceration anywhere in the GI tract.