Angina

Question 1

What causes angina?

What is the difference between stable and unstable angina?

Answer 1

Angina is a symptom

Insufficient blood flow to myocardium arising from narrowing of arteries. Caused by plaques in arteries

Stable angina: when symptoms are always relieved by rest or glyceryl trinitrate (GTN).

Unstable angina: when the symptoms come on randomly whilst at rest,

Question 2

What underlying pathologies might cause angina if the problem is occuring from a reduced o2 supply? [2]

Answer 2

Reduced O2 demand:

1. CAD:
   - Atherosclerosis
   - Post radiation therapy
   - Spasm: normal coronary arteries which spasm causing temporary occlusion
2. Anaemia

Question 3

What underlying pathologies might cause angina if the problem is occuring from an increased myocardial demand? [3]

Answer 3

1. Left ventricular hypertrophy (from: HTN, aortic stenosis, aortic regurgiation, hypertrophic cardiomyopathy)
2. Right ventricular hypertophy (from: pulmonary HTN, pulmnonary stenosis)
3. Rapid tachycardiarythmias

Question 4

Describe the pathway you would undertake to diagnose stable angina

Answer 4

Clinical assesment:
How many of the following do they have?
- General chest discomfort lasting 5/10 mins?
- Is this provoked by exercise?
- Is this relieved by rest or nitrates?

2. Answer = <1, No diagnostic testing, no medication
3. Answer = 2 characteristics = atypical angina
4. Answer = 3 characteristics = typical angina

If Atypical angina or typical angina: initial management and investigations:
- CTCA
- Functional imaging if CTCA inconclusive

Question 5

What key factors about chest pain would you ask someone with angina? [5]

Answer 5

Character
Location
Radiation
Duration
Provocation

Question 6

What is the gold standard for anatomical testing for why angina might be occuring?

Answer 6

Angina is a manifestation of coronary arterial atheroma - can lead to plaque build up

CTCA - CT Coronary Angiogram is best

Question 7

What results from CTCA can be useful for diagnosis of the cause of angina? [2]

Answer 7

Ca2+ levels (elevated levels are associated with worse prognosis)

Angiography

Question 8

Describe the managment pathway for someone with angina

Answer 8

Question 9

How do different drugs / therapies target different physiological areas to relieve angina symptoms?

Answer 9

Increasing O2 delivery
Increase coronary blood flow:
- Nitrates
- CCBs
- Revasc.
- Nicorandil (Combination of K+ blocker and nitrate)

Reducing myocardial demand:

1. Reduce HR:
- BB
- ivabradine

2. Decrease LV wall tension:
- BB
- Nitrates
- Nicorandil
- CCBs
- Ranolazine (Na+ pump inhibitor)

3. Reduce contractility:
- BB
- CCBs

4. Modify energy metabolism
- Trimetazidine

Question 10

How can you reduce risk of MI for patients who are at risk of angina?

Answer 10

1. Aspirin: this produces an antithrombotic effect that helps to reduce the risk of heart attacks and strokes.
2. Statins: reduces cholesterol (HMG Reductase inhibitor)
3. Ace Inhibitor: If there is hypertension or diabetes or other comorbidities
4. P2Y12 receptor
   antagonist: After PCI or if allergic to statins

Question 11

Who are the ‘no option’ patients?

Answer 11

Patients with heart failure or angina who remain refractory to conventional therapies

Question 12

What is most critical with diagnosing patient with angina?

Answer 12

History and examination are the cornerstones of diagnosis (the scores)

Adjunctive anatomical and functional imaging support the clinical diagnosis

Question 13

What lifestyle modifications should be advised if have angina? [5]

Answer 13

Stop smoking
Stop drinking
Reduce weight
Reduce stress
Healthy diet
Increase physical activity

Question 14

When do you move from treatment of drugs to a revasc procedure (PCI or CABG?) [2]

Answer 14

If symptoms are ongoing [1]
If having an MI [1]

Question 15

What drug is initially used to treat stable angina? [1]

Answer 15

glyceryl trinitrate (GTN).