Angina Flashcards
Clinical observations to perform
Obs - BP, sats, HR, distress?
Clinical examinations to perform
Chest is clear?
Any murmur?
JVP elevated?
Peripheral oedema?
Atypical chest pain characteristics?
Pleuritic pain, sharp or knife-like pain
related to respiratory movements or cough
Primary or sole location in the mid or lower abdominal region
Any discomfort localized with one finger
Any discomfort reproduced by movement or palpation
Constant pain
lasting for days
Fleeting pains lasting
for a few seconds or
less
Pain radiating into
the lower extremities
or above the
mandible
Difference between myocardial ischeamia, infarction and injury
Ischaemia - ischeamic symptoms; chest, upper extremity, mandibular or epigastric discomfort during exertion of at rest or iaschaemic equivalent e.g. dyspnoea
Injury - increased troponin
Infarct - ischaemic symptoms, ECG changes and troponin changes
What is unstable angina?
Myocardial ischamia at rest or on minimal exertion in the absence of cardiomyocyte injury/necrosis and absence of troponin rise
How can we confirm a diagnosis of angina?
- invasive angiography if suspicion of high-risk obstructive CAD and severe M schema
Functional imaging in patients with mod-high clinical likelihood
CCTA in individuals with low and moderate clinical likelihood
Lifestyle intervention for RF control
Smoking and substance abuse
Obesity and overweight
Hyperlipidaemia
Diabetes
HTN
Diet
Physical activity
Treatment
- tailor the selection of antianginal drugs to patient’s characteristics, comorbidities, concomitant meds, tolerability
- short-acting nitrates recommended for immediate relief of angina
- BB and/or CCBs recommended to control heart rate and symptoms for most patients with chronic coronary syndrome
- Long acting nitrates or ranolazine can be considered if symptoms can’t be controlled while on BB and/or CCBs
Ivabradine can be considered in pts with LVEF 40% less and inadequate control of symptoms
Long-term antithrombotic therapy in pts with chronic coronary syndrome and no clear indication for OAC :
Pts with prior MI or remote PCI -> lifelong
- aspirin 75-100mgdaily or clopidrogrel 75mgdaily
Pts without prior MI or revascularisation but with evidence of significant obstructive cAD - aspirin 75-100mg daily.
A high intensity statin to reach LDL goals is recommended in pts with CCS
Nice guideline treatment of stable angina
Drugs for treating stable angina
1.4.7 Offer either a beta blocker or a calcium channel blocker as first-line treatment for
stable angina. Decide which drug to use based on comorbidities,
contraindications and the person’s preference.
1.4.8 If the person cannot tolerate the beta blocker or calcium channel blocker,
consider switching to the other option (calcium channel blocker or beta blocker).
1.4.9 If the person’s symptoms are not satisfactorily controlled on a beta blocker or a
calcium channel blocker, consider either switching to the other option or using a
combination of the two.
When combining a calcium channel blocker with a beta blocker, use a
dihydropyridine calcium channel blocker, for example, slow release nifedipine,
amlodipine or felodipine.
1.4.10 Do not routinely offer anti-anginal drugs other than beta blockers or calcium
channel blockers as first-line treatment for stable angina.
1.4.11 If the person cannot tolerate beta blockers and calcium channel blockers or both
are contraindicated, consider monotherapy with one of the following drugs:
* a long-acting nitrate or
* ivabradine or
* nicorandil or
* ranolazine.
Decide which drug to use based on comorbidities, contraindications, the
person’s preference and drug costs.
Since this guidance was produced, the Medicines and Healthcare products
Regulatory Agency (MHRA) have published new advice about safety
concerns related to ivabradine (June 2014 and December 2014) and
nicorandil (January 2016).
1.4.12 For people on beta blocker or calcium channel blocker monotherapy whose
symptoms are not controlled and the other option (calcium channel blocker or
beta blocker) is contraindicated or not tolerated, consider one of the following as
an additional drug:
* a long-acting nitrate or
* ivabradine or
* nicorandil or
* ranolazine.
Decide which drug to use based on comorbidities, contraindications, the
person’s preference and drug costs.
Since this guidance was produced, the Medicines and Healthcare products
Regulatory Agency (MHRA) have published new advice about safety
concerns related to ivabradine (June 2014 and December 2014) and
nicorandil (January 2016).
When combining ivabradine with a calcium channel blocker, use a
dihydropyridine calcium channel blocker, for example, slow release nifedipine,
amlodipine, or felodipine.
1.4.13 Do not offer a third anti-anginal drug to people whose stable angina is controlled
with two anti-anginal drugs.
1.4.14 Consider adding a third anti-anginal drug only when:
* the person’s symptoms are not satisfactorily controlled with two anti-anginal
drugs and
* the person is waiting for revascularisation or revascularisation is not
considered appropriate or acceptable.
Decide which drug to use based on comorbidities, contraindications, the
person’s preference and drug costs.
People with stable angina whose symptoms are not satisfactorily
controlled with optimal medical treatment - NICE
Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous
coronary intervention [PCI]) for people with stable angina whose symptoms are
not satisfactorily controlled with optimal medical treatment.
1.5.2 Offer coronary angiography to guide treatment strategy for people with stable
angina whose symptoms are not satisfactorily controlled with optimal medical
treatment. Additional non-invasive or invasive functional testing may be required
to evaluate angiographic findings and guide treatment decisions. [This
recommendation partially updates recommendation 1.2 of the NICE technology
appraisal guidance on myocardial perfusion scintigraphy for the diagnosis and
management of angina and myocardial infarction.]
1.5.3 Offer CABG to people with stable angina and suitable coronary anatomy when:
* their symptoms are not satisfactorily controlled with optimal medical
treatment and
* revascularisation is considered appropriate and
* PCI is not appropriate.
1.5.4 Offer PCI to people with stable angina and suitable coronary anatomy when:
* their symptoms are not satisfactorily controlled with optimal medical
treatment and
* revascularisation is considered appropriate and
* CABG is not appropriate.
1.5.5 When either procedure would be appropriate, explain to the person the risks and
benefits of PCI and CABG for people with anatomically less complex disease
whose symptoms are not satisfactorily controlled with optimal medical treatment.
If the person does not express a preference, take account of the evidence that
suggests that PCI may be the more cost-effective procedure in selecting the
course of treatment.
1.5.6 When either procedure would be appropriate, take into account the potential
survival advantage of CABG over PCI for people with multivessel disease whose
symptoms are not satisfactorily controlled with optimal medical treatment and
who:
* have diabetes or
* are over 65 years or
* have anatomically complex three-vessel disease, with or without involvement
of the left main stem.
1.5.7 Consider the relative risks and benefits of CABG and PCI for people with stable
angina using a systematic approach to assess the severity and complexity of the
person’s coronary disease, in addition to other relevant clinical factors and
comorbidities.
1.5.8 Ensure that there is a regular multidisciplinary team meeting to discuss the risks
and benefits of continuing drug treatment or revascularisation strategy (CABG or
PCI) for people with stable angina. The team should include cardiac surgeons and
interventional cardiologists. Treatment strategy should be discussed for the
following people, including but not limited to:
* people with left main stem or anatomically complex three-vessel disease
- people in whom there is doubt about the best method of revascularisation
because of the complexity of the coronary anatomy, the extent of stenting
required or other relevant clinical factors and comorbidities.
1.5.9 Ensure people with stable angina receive balanced information and have the
opportunity to discuss the benefits, limitations and risks of continuing drug
treatment, CABG and PCI to help them make an informed decision about their
treatment. When either revascularisation procedure is appropriate, explain to the
person: - The main purpose of revascularisation is to improve the symptoms of stable
angina. - CABG and PCI are effective in relieving symptoms.
- Repeat revascularisation may be necessary after either CABG or PCI and the
rate is lower after CABG. - Stroke is uncommon after either CABG or PCI, and the incidence is similar
between the two procedures. - There is a potential survival advantage with CABG for some people with
multivessel disease.
1.5.10 Inform the person about the practical aspects of CABG and PCI. Include
information about: - vein and/or artery harvesting
- likely length of hospital stay
- recovery time
- drug treatment after the procedure.
Secondary prevention of CVD with stable angina NICE
Drugs for secondary prevention of cardiovascular disease
1.3.5 Consider aspirin 75 mg daily for people with stable angina, taking into account
the risk of bleeding and comorbidities.
1.3.6 Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable
angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line
with relevant NICE guidance.
1.3.7 Offer statin treatment in line with the NICE guideline on lipid modification.
1.3.8 Offer treatment for high blood pressure in line with the NICE guideline on
hypertension.
Stable angina: management (CG126)
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Dietary supplements
1.3.9 Do not offer vitamin or fish oil supplements to treat stable angina. Inform people
that there is no evidence that they help stable angina.
Preventing and treating episodes of angina - NICE
Preventing and treating episodes of angina
1.3.3 Offer a short-acting nitrate for preventing and treating episodes of angina. Advise
people with stable angina:
* how to administer the short-acting nitrate
* to use it immediately before any planned exercise or exertion
* that side effects such as flushing, headache and light-headedness may occur
* to sit down or find something to hold on to if feeling light-headed.
1.3.4 When a short-acting nitrate is being used to treat episodes of angina, advise
people:
* to repeat the dose after 5 minutes if the pain has not gone
* to call an emergency ambulance if the pain has not gone 5 minutes after
taking a second dose.
