Angina

Question 1

What are the different types of angina?

Answer 1

Stable- present on exertion, relieved by rest/GTN, lasts <10 minutes

Unstable- new onset, present at rest, rapidly progressive pain (increased frequency of episodes)

Question 2

How should potential angina be assessed?

Answer 2

1) Categorise pain as typical, atypical or non anginal
- Constricting affecting chest/arms or neck
- Symptoms precipitated by exercise
- Symptoms relieved within 5 mins of GTN or rest

Typical= 3/3
Non typical= 2/3
Non anginal=1/3
- if no risk factors then not angina

Question 3

What investigations are required?

Answer 3

1) CT coronary angio
2) If CTCA inconclusive/lnown CARD
- images to demonstrate reversibe/inducible ischaemia
- Cardiac MRI, Myocardial perfusion scan, Stress ECHO
- Exercise ECG if known CAD

Diagnosis of stable
- significant CAD on CTCA or reversible ischaemia on non invasive functional testing

3) Invasive coronary angio

Question 4

What is the management?

Answer 4

Secondary prevention

Statin
Aspirin 75mg OD
GTN- if >2 doses and pain persists then 999
ACEi- if diabetes, HTN, HF, CKD or MI

Question 5

What is the management of angina?

Answer 5

1) Beta blocker or CCB (verapamil)
- caution BB in asthma
2) Betablocker AND CCB
- if taking BB add long acting CCB e.g. nifedipine, amlodipine
- If taking dihydropyridine CCB- add BB

Do not prescribe BB and rate limiting CCB due to risk of bradycardia/heart block

3) If monotherapy/2nd drug contraindicated add either
- Long acting nitrate
- Ivabradine
- Ranolazine

4) If requiring 3rd drug then refer for angio/revascularisation
- only add whilst awaiting review
- CABG preferred if patient diabetic/ >65./ triple vessel disease

Question 6

What are SE of nitrates?

Answer 6

Lead to vasodilation

SE
- Hypotension
- Tachycardia
- Flushing
- Headaches
- Reflux

Question 7

What are SE of Ivabradine?

Answer 7

Reduces HR

SE
- Luminous phenomena- halos/coloured bright lights
- Bradycardia
- Peripheral oedema