Angina

Question 1

3 features of typical angina

Answer 1

1) Symptoms on exertion
2) Chest/neck/shoulder/jaw/arm pain
3) Symptoms relieved by 5 minutes rest or by GTN within 5 minutes

Question 2

Atypical angina

Answer 2

2/3 of typical angina criteria
Symptoms may include GI discomfort/SOB/nausea
Alternative triggers - stress/cold/large meal

Question 3

ECG changes in angina/previous MI

Answer 3

1) Pathological Q waves
2) LBBB
3) ST changes
4) T wave flattening/elevation/inversion
5) Can be normal

Question 4

Initial treatment of angina whilst awaiting diagnosis

Answer 4

1) GTN - lie down, 2nd dose can be given > 5 minutes, if chest pain > 5 minutes after 2nd dose/unwell/pain increasing call 999

2) Aspirin 75mg OD if angina likely

Question 5

Treatment - newly diagnosed angina

Answer 5

1) GTN

2) BB (atenolol 100mg OD/BD) or CCB (rate-limiting preferred) - if both CI isosorbide mononitrate/nicorandil/ivabradine/ ranolazine - Review in 2-4 weeks and titrate against symptoms to **maximum tolerated dose
**
3) Antiplatelet - aspirin 75mg OD, unless already on clopidogrel (PAD/CVA)

4) Consider ACEI if DM and ensure on ACEi if coexistent HTN/HF/ asymptomatic LVD/ CKD/previous MI

5) Offer statin

Question 6

Driving advice in angina

Answer 6

G1 - stop if pain at rest/emotion/driving and restart when symptom control achieved

G2 - stop + notify DVLA when symptoms occur. Can start when symptoms controlled for > 6 weeks + any test requirements met. Check insurance covers angina

Question 7

Sex advice in angina

Answer 7

1) If sex triggers CP, can take GTN immediately before
2) Avoid PDE inhibitors, but if essential ensure 12h between avanafil and nitrate or 24h between sildenafil and nitrate and do not use GTN
3) Call 999 if CP > 10 minutes

Question 8

Flying advice in angina

Answer 8

1) Safe to fly if no recent increase in symptoms and only symptomatic on intense exertion
2) If symptoms on minimal exertion may need assistance and inflight O2
3) Defer if worsening symptoms or symptoms at rest

Question 9

Management if symptoms poorly controlled

Answer 9

1) Ensure on **maximum tolerated dose **of BB or CCB

2) If on monotherapy
- switch/add in BB or CCB
- do not combine BB with rate-limiting CCB (diltiazem/verapamil) due to risk of severe bradycardia and HF, use dihydropyridine CCB instead (amlodipine/felodipine)

3) If on dual therapy
- ensure on maximum tolerated dose of both
- if still not well controlled, refer to cardiology for assessment for revascularisation (PCI/CABG). Can add 3rd medication while waiting (nitrate/nicrorandil)

Question 10

Nitrates: contraindications, dosing, side effects

Answer 10

CI: aortic/mitral stenosis, HOCM, severe anaemia/closed angle glaucoma

Dosing of immediate release: asymmetric daily dosing 7-8h apart, to ensure 10-14h nitrate free period and avoid tolerance

Use modified release so constant low dose of nitrate if risk of non-compliance to asymmetric dosing

SE: headache usually improves within 2 weeks. If GTN tablets cause mouth stinging switch to lower dose or spray

Question 11

Which CCB to choose in angina if not on BB and CI of this

Answer 11

Rate-limiting CCB - diltiazem or verapamil

CI: AF/WPW/HF/low HR/HB/aortic stenosis/HOCM

Question 12

Which CCB to choose in angina if on BB and CI of this

Answer 12

Dihydropyridine - amlodipine or felodipine

When combined with BB can cause reflex tachycardia and worsening of symptoms

CI: uncontrolled HF/aortic stenosis

SE: ankle swelling

Question 13

Which CCB to choose if patient has angina + HF

Answer 13

Amlodipine or felodipine

Question 14

Which BB to choose if patient has angina + HF

Answer 14

Bisoprolol, carvedilol or nebivolol

Question 15

CI of BB

Answer 15

Asthma/reversible or severe COPD/HR < 60/HB/Raynaud’s/hypo’s

Question 16

Nicrorandil caution

Answer 16

Caution in diverticular disease due to risk of bowel perforation
Associated with ulcers anywhere along GI tract