Angina

Question 1

What is angina?

Answer 1

Chest pain (or constricting discomfort) caused by insufficient blood supply to the heart muscle

Question 2

What is the difference between stable and unstable angina?

Answer 2

Stable - occurs predictably with exertion, stress, heavy meals - lasts <10 mins - relieved by rest or by sublingual nitrate (GTN)

Unstable - new onset angina (usually <24hrs) or abrupt deterioration in previously stable angina - often occurring at rest - medical emergency

Question 3

How is angina caused?

Answer 3

Atherosclerosis in the coronary arteries

Question 4

What is the symptomatic diagnosis of angina?

Answer 4

Typical angina: All 3 of:
- Comstricting discomfort in front of chest, neck, shoulders, jaw, arms
- precipitated by physical exertion
- relieved by rest/GTN within 5 mins

Question 5

What medication provides symptom relief from angina, how does it work ans what are some side effects?

Answer 5

Glyceryl trinitrate (GTN) - sublingual tablets and spray

Acts directly on vascular smooth muscle causing profound vasodilation and improved myocardial perfusion

Flushing, headache, light headedness

Question 6

When should GTN be used and when should the dose be repeated?

Answer 6

When pain occurs or before any activity

Repeat dose (1-2 sprays, 1 tab) after 5 mins if pain persists, 999 of persists 5 mins after 2nd dose.

Question 7

What are the 1st line regular anti-anginals and when should the response be reviewed?

Answer 7

Beta blockers / calcium channel blockers (choice on co morbides, contraindications, preference)

2-4 weeks.

Question 8

What are some examples of 2nd line anti anginals, that can also be added for dual therapy?

Answer 8

Isosorbide mononitrate and Nicorandil

Question 9

What are some unsuitable combinations for dual therapy due to a risk of excessive bradycardia/heart block?

Answer 9

Beta blocker and rate-limiting CCB e.g. Diltiazem
Ivabradine and rate-limiting CCB

Question 10

What is the first line beta blocker and its dose for angina?

Answer 10

Bisoprolol, initially 2.5mg OD

Question 11

What are the first line calcium channel blockers?

Answer 11

Dihydropyridine - Amlodipine 5mg OD
Non-dihydropyridine - Diltiazem (Note: BRAND RX above 60mg strength)

Question 12

What is an example of a long acting nitrate and why are m/r preparations preferred?

Answer 12

Isosorbide mononitrate

To avoid tolerance

Question 13

What drug interactions occur with Nicorandil?

Answer 13

Sildenafil and tadalafil, meds causing GI ulceration (NSAIDS, corticosteroids)

Question 14

What should be commenced as secondary prevention for managing stable angina? (unless C/I’d)

Answer 14

• Aspirin 75mg OD or Clopidogrel 75mg OD if CI
• Atorvastatin 80mg OD
• If HTN -> ACE inhibitor
  (Note: optimise glycaemic control if diabetic)