Angina

Question 1

.. is a second-line anti-anginal therapy that inhibits late inward sodium channels, which reduced calcium overload in cardiomyocytes.

Answer 1

Ranolazine is a second-line anti-anginal therapy that inhibits late inward sodium channels, which reduced calcium overload in cardiomyocytes.

Question 2

Ranolazine may be given to patients who have inadequately controlled stable angina on first-line anti-anginal medications including beta-blockers and/or calcium channel blockers. Ranolazine should be used with caution in the elderly and patients with moderate to severe congestive heart failure.
Other anti-anginals include:

Answer 2

Ranolazine may be given to patients who have inadequately controlled stable angina on first-line anti-anginal medications including beta-blockers and/or calcium channel blockers. Ranolazine should be used with caution in the elderly and patients with moderate to severe congestive heart failure.

Other anti-anginals include:

• Nitrates: Relax vascular smooth muscle and increases coronary blood flow
• Ivabradine: Lowers heart rate through inhibition of cardiac ‘funny channels’
• Nicorandil: Potassium channel agonist, which inhibits voltage-gated calcium channels leading to muscle relaxation
• Calcium channel blockers: Inhibit influx of calcium ions into both vascular smooth muscle and cardiac muscle

Question 3

.. should be used with caution in the elderly and patients with moderate to severe congestive heart failure.

Answer 3

Ranolazine should be used with caution in the elderly and patients with moderate to severe congestive heart failure.

Question 4

What is the most common cause of angina?

Answer 4

Angina is most commonly due to coronary artery disease that refers to formation of atherosclerotic plaques within the coronary vessels.

Question 5

What should be given to patients to relieve episodes of angina?

Answer 5

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray 1 to 2 doses under the tongue for an attack of angina. If pain has not subsided in 5 minutes they should repeat the dose. If the pain is ongoing after 10 minutes they should call for an ambulance.

Question 6

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include … (2)

Answer 6

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure.

Question 7

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray how much and where?

Answer 7

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray 1 to 2 doses under the tongue for an attack of angina.

Question 8

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray 1 to 2 doses under the tongue for an attack of angina. If pain has not subsided in … minutes they should repeat the dose. If the pain is ongoing after … minutes they should call for an ambulance.

Answer 8

If pain has not subsided in 5 minutes they should repeat the dose. If the pain is ongoing after 10 minutes they should call for an ambulance.

Question 9

Beta-blockers (e.g. bisoprolol) and calcium channel blockers (e.g. amlodipine) work by decreasing the oxygen demand of cardiomyocytes. They are typically used as first line … treatments for angina.

Answer 9

Beta-blockers (e.g. bisoprolol) and calcium channel blockers (e.g. amlodipine) work by decreasing the oxygen demand of cardiomyocytes. They are typically used as first line preventative treatments for angina.

Question 10

What two drug classes are typically used as first line preventative treatments for angina?

Answer 10

Beta-blockers (e.g. bisoprolol) and calcium channel blockers (e.g. amlodipine) work by decreasing the oxygen demand of cardiomyocytes. They are typically used as first line preventative treatments for angina.

Question 11

Angina consists of three classical features:

Answer 11

Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw

Precipitated by physical exertion

Relieved by rest or GTN within 5 minutes

Question 12

Angina vs unstable angina

Answer 12

Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw

Precipitated by physical exertion

Relieved by rest or GTN within 5 minutes

The pain associated with unstable angina typically occurs at rest. It is broadly defined as a sudden new onset of angina or a significant, and abrupt, deterioration in angina that has been stable.

Question 13

Angina

Answer 13

Angina refers to the central pressing, squeezing, or constricting chest discomfort that is experienced when there is a reduction in blood flow through the coronary arteries. There may be typical radiation to the arm, jaw or neck and it is bought on by physical or emotional exertion and relieved by rest. It typically lasts < 10 minutes.

Question 14

Angina is the main symptom of myocardial …, which is usually secondary to coronary artery disease (CAD). However, other conditions can cause angina such as coronary spasm, severe ventricular hypertrophy or severe aortic stenosis.

Answer 14

Angina is the main symptom of myocardial ischaemia, which is usually secondary to coronary artery disease (CAD). However, other conditions can cause angina such as coronary spasm, severe ventricular hypertrophy or severe aortic stenosis.

Question 15

An estimated 2 million people in England have, or have experienced angina. Patients with angina secondary to CAD are at risk of a major cardiac event:

Answer 15

Myocardial infarction (MI)
Cardiac arrest
Death

Question 16

Stable vs unstable angina

Answer 16

Stable angina refers to pain that occurs predictably with physical or emotional exertion and lasts no longer than 10 minutes. It should be relived within minutes of rest or with the use of medication (e.g. GTN spray).

Unstable angina refers to a sudden new onset of angina or a significant, and abrupt, deterioration in angina that has been stable. This typically relates to pain that increases with frequency and severity or pain that is experienced at rest. Patients experiencing unstable angina symptoms need urgent admission to hospital for exclusion of acute coronary syndrome (ACS).

Question 17

CAD refers to the development of …

Answer 17

CAD refers to the development of atherosclerotic plaques within the coronary vessels, which limits blood flow and precipitates symptoms. There are several risk factors for the development or atherosclerosis (listed below).

Question 18

Modifiable risk factors: angina

Answer 18

High cholesterol
Hypertension
Smoking
Diabetes
Obesity

Question 19

Non-modifiable risk factors: angina

Answer 19

Age
Family history
Male sex
Premature menopause

Question 20

Several other conditions may cause ischaemia through reduced coronary artery blood flow or an increased oxygen supply/demand mismatch.

Answer 20

Coronary artery spasm (Prinzmetal angina)
Microvascular angina (diffuse vascular disease within the microvasculature of the coronary circulation)
Vasculitis (e.g. Kawasaki disease, polyarteritis nodosa)
Anaemia (oxygen supply/demand mismatch)
Severe left ventricular hypertrophy (reduced subendocardial blood flow and increased susceptibility to ischaemia)
Severe aortic stenosis (increases myocardial oxygen demand)

Question 21

CAD is a dynamic process that results from atherosclerotic obstruction of coronary vessels (discussed below). It may present in different ways, which are broadly grouped into two categories:

Answer 21

Acute coronary syndrome (ACS)

Chronic coronary syndrome (CCS)

Question 22

… is an inflammatory process which predisposes individuals to angina and ACS.

Answer 22

Atherosclerosis is an inflammatory process which predisposes individuals to angina and ACS.

The development of atherosclerosis is a complex process that involves lipids, macrophages and smooth muscle. Atherosclerosis leads to the formation of an atheroma, which contains a hard plaque on its surface. This plaque is at risk of rupture, which may lead to ACS.

The presence of atherosclerosis within coronary vessels is termed coronary artery disease (CAD) or ischaemic heart disease (IHD) and it may be obstructive (i.e. >50% of the vessel lumen) or non-obstructive (<50% of the vessel lumen).

Atherosclerosis develops in three steps: endothelial dysfunction, plaque formation, plaque rupture.

Question 23

The three classic features of angina include:

Answer 23

Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw
Precipitated by physical exertion
Relieved by rest or GTN within 5 minutes

Question 24

Based on these classical features, angina can be differentiated into three types:

Answer 24

Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw
Precipitated by physical exertion
Relieved by rest or GTN within 5 minutes
Based on these classical features, angina can be differentiated into three types:

Typical: all three of the above features
Atypical: two of the above features
Non-anginal: ≤1 of the above features

Question 25

The following features are more suggestive of non-anginal chest pain, but it is important to consider these in the context of cardiovascular risk factors:

Answer 25

Continuous or very prolonged pain, and/or
Unrelated to activity, and/or
Bought on by breathing, and/or
Associated with dizziness, palpitations, paraesthesia

Question 26

Other features - angina

Answer 26

Dyspnoea: maybe the only presenting feature of CAD in the absence of chest pain. Consider CAD if precipitated by exertion and improved on rest.
Palpitations: angina may be precipitated by tachyarrhythmias (e.g. atrial fibrillation). These increase the oxygen supply/demand mismatch and reduce the filling time of the coronary vessels during diastole.
Syncope: may be suggestive of dangerous valvular or cardiac muscle disease causing angina, particularly if it occurs on exertion.

Question 27

Concerning chest pain

Answer 27

Chest pain lasts > 10 minutes
Chest pain not relieved by two doses of GTN taken 5 minutes apart
Significant worsening/deterioration in angina (e.g. increased frequency, severity or occurring at rest)

Question 28

Grading angina

The severity of angina can be graded according to the Canadian Cardiovascular Society.

Answer 28

Grade I: angina with strenuous activity (e.g. limitation on strenuous or prolonged ordinary activity).
Grade II: angina with moderate activity (e.g. slight limitation if normal activities performed rapidly).
Grade III: angina with mild exertion (e.g. difficulty climbing one flight of stairs at normal pace).
Grade IV: angina at rest (e.g. no exertion needed to trigger).

Question 29

The diagnostic work-up of angina should aim to:

Answer 29

Exclude the possibility of ACS: if concern, follow ACS guidelines
Determine the typicality of angina symptoms and functional ability of the patient
Undertake basic investigations (e.g. blood tests, ECG, echocardiography +/- chest x-ray)
Determine the probability of CAD: based on history, examination, and basic investigations
Offer diagnostic testing where appropriate
Offer appropriate therapy: this is based on the perceived risk of a major cardiac event (e.g. MI, death)

Question 30

Rapid access chest pain clinic

Answer 30

In the UK, patients with new-onset exertional chest pain suspected to be angina should have access to a rapid access chest pain clinic (RACPC). These clinics provide patients with early access to specialist cardiology assessment including diagnostic testing. It aims to identify new CAD and prevent a major cardiac event by offering earlier intervention.

In patients with established CAD, who are already known to cardiology services, development of angina should be discussed in cardiology clinic (locality dependent).

Question 31

First-line investigations for determining if patients have evidence of CAD or major risk factors for CAD (e.g diabetes mellitus). They should be completed as an outpatient, usually in a RACPC, unless there is concern about ACS (follow ACS guidelines).

Answer 31

Blood tests: FBC, U&Es, Lipid profile, blood glucose, HbA1c (TFTs if concern re. thyroid disease)
Resting ECG: look for indirect signs of CAD (e.g. pathological q waves, conduction abnormalities, ST-T wave changes).
Echocardiography: essential to assess LV function, valvular pathology and any motion abnormalities (sign of ischaemic disease).
Chest x-ray: may be needed if atypical symptoms, features of heart failure or suspicion of pulmonary disease.
NOTE: troponin should only be completed if there is concern about unstable symptoms (i.e. acute coronary syndrome)

Question 32

This refers to the likelihood of CAD based on age, sex and typicality of symptoms. The pre-test probability helps guide what further testing is required, if any, to determine the presence of CAD.

Answer 32

Pre-test probability >15%: non-invasive functional testing recommended
Pre-test probability 5-15%: consider further testing based on basic investigations and risk factors.

Question 33

A CT coronary angiography (CTCA) allows visualisation of the …

Answer 33

A CT coronary angiography (CTCA) allows visualisation of the coronary artery lumens.

CTCA should be offered to patients deemed to be low risk as a way of excluding CAD. If obstructive CAD is identified, patients require further functional or invasive testing to determine the significance of obstruction.

Obstructive CAD defined as:

≥ 70% stenosis of ≥1 major coronary artery segment, OR
≥ 50% stenosis in the left main coronary artery

Question 34

A number of functional non-invasive tests can be offered to patients to look for myocardial ischaemia.

Examples include:

Answer 34

Dobutamine stress echocardiography
Stress or contrast cardiac MRI
Perfusion changes by single-photon emission CT (SPECT)

Question 35

Exercise ECG

Answer 35

Exercise ECG is a traditional functional test that involves a patient running on a treadmill and observing for clinical symptoms and ECG changes suggestive of ischaemia (e.g. ST depression). However, this type of functional test is inferior to other non-invasive and anatomical testing. Therefore, the European Society of Cardiology recommend imaging testing instead of exercise ECG

Question 36

Patients should be risk stratified to determine the need for revascularisation therapy.

Answer 36

High risk: >3% annual risk of cardiac mortality

Low risk: <1% annual risk of cardiac mortality

Question 37

Addressing lifestyle factors decreases the risk of major cardiac event and mortality. Factors to address:

Answer 37

Diet: high in vegetables, fruit, and wholegrains. Limit saturated fat to <10% of total intake.
Alcohol: limit alcohol to <100 g/week (12.5 units/week)
Smoking: smoking cessation
Exercise: 30-60 minutes of moderate activity. Even irregular exercise beneficial.
Weight reduction: aim for healthy BMI (18-25 kg/m2)

Question 38

Pharmacological management - angina

Answer 38

Pharmacological management

All patients should be offered a short-acting nitrate PRN (e.g. sublingual GTN) to relieve episodes of angina.

Question 39

PRN therapy - angina

Answer 39

A short-acting nitrate, such as sublingual Glyceryl trinitrate (GTN), should be given to patients to relieve episodes of angina. It works by causing vascular smooth muscle relaxation, which improves coronary blood flow. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray 1 to 2 doses under the tongue for an attack of angina. If pain has not subsided in 5 minutes they should repeat the dose. If the pain is ongoing after 10 minutes they should call for an ambulance.

Question 40

First line treatment - angina

Answer 40

Patients should be offered either a beta-blocker or calcium channel blocker as a first-line treatment. These drugs work by decreasing oxygen demand of the heart muscle. If symptoms are ongoing despite maximal dose the agents can be used in combination. Amlodipine is commonly used, which is a dihydropyridine calcium channel blocker.

Non-dihydropyridine calcium channel blockers, such as verapamil or diltiazem, are contraindicated with beta-blockers due to the risk of atrioventricular block (i.e. heart block). Occasionally they may be used in angina treatment as monotherapy. They should be avoided in heart failure.

Question 41

Second line treatment - angina

Answer 41

If patients cannot tolerate beta-blockers or calcium channel blockers, then monotherapy with one of the following medications may be offered:

Long-acting nitrate (e.g. isosorbide mononitrate): relaxation of vascular smooth muscle and increases coronary blood flow
Ivabradine: lowers heart rate through inhibition of cardiac ‘funny channels’
Nicorandil: potassium channel agonist, which inhibits voltage-gated calcium channels leading to muscle relaxation
Ranolazine: inhibition of late inward sodium channel, which reduces calcium overload in cardiomyocytes.
Different combinations of these second-line options may be given alongside beta-blockers and calcium channel blockers. This is if patients have ongoing symptoms despite maximal medical therapy. Choice depends on heart rate, LV function and blood pressure.

Question 42

Invasive management - angina

Answer 42

Revascularisation therapy is an option in patients who are high risk of a major cardiac event or refractory to medical therapy.

Question 43

Revascularisation (PCI)

Answer 43

Coronary angiography with percutaneous coronary intervention (PCI) involves insertion of a stent into a coronary artery to improve blood flow and therefore symptoms. PCI may be offered to coronary arteries with significant stenosis or where the flow across a diseased artery, as measured by the fractional flow reserve (FFR), is significantly limited.

Following a stent insertion for ‘stable’ angina, dual anti-platelet therapy should be offered for a minimum of 6 months (e.g. aspirin and clopidogrel). Patients at higher risk may be considered for long therapy.

Question 44

Coronary artery bypass grafting is a cardiothoracic surgical procedure that aims to …

Answer 44

Coronary artery bypass grafting is a cardiothoracic surgical procedure that aims to restore flow within a coronary vessel through bypass of the obstructed segment. This usually involves using vein grafts or redirecting flow from the internal mammary artery.

Question 45

Coronary artery bypass grafting is a cardiothoracic surgical procedure that aims to restore flow within a coronary vessel through bypass of the obstructed segment. This usually involves using vein grafts or redirecting flow from the internal mammary artery.

Answer 45

> 50% stenosis of the left main stem
70% stenosis of proximal left anterior descending and circumflex arteries
Triple-vessel disease (asymptomatic or symptomatic)
Triple-vessel disease with proximal LAD stenosis and poor LV function

Question 46

Patients who may qualify for a CABG should be discussed in the joint cardiology/cardiothoracic (JCC) meeting. Decision between PCI or CABG depends on…

Answer 46

Patients who may qualify for a CABG should be discussed in the joint cardiology/cardiothoracic (JCC) meeting. Decision between PCI or CABG depends on fitness for surgery, coronary anatomy, vessel involvement and patient choice.