Angina Flashcards
What is stable angina
Chest pain by not enough oxygen being delivered to the myocardium due to blood vessels being narrowed or the coronary arteries going into spasm.
What causes unstable angina
When the fibrous cap of the atheroma in the coronary artery ruptures, allows thromboses to form and decrease the lumen
What are the symptoms of angina
Central chest pain relieved by rest or GTN spray
Pain may radiate to arm, jaw or neck
What are the risk factors for angina
Hypertension Hyperlipidaemia Obesity Coronary artery disease Diabetes mellitus Smoking Previous MI family hx of heart disease
Which investigations would be done on a patient with chest pain
ECG - may show some ischaemic changes however will most likely be normal however this does not rule out angina. Rules out STEMI
Exercise ECG - stopped when chest pain begins or ECG changes
Bloods:
FBC - rule out anaemia
U&es for renal function and electrolyte imbalances
Fasting blood glucose
Fasting blood cholesterol
Baseline LFTs before starting statins
TFTs - hyper can increase HR and hypo is associated with high cholesterol
Troponins and cardiac enzymes if MI suspected
Echo if hypertrophic cardiomyopathy or valve disease suspected
What are the differentials for chest pain
CVS - angina both stable and unstable, STEMI, NSTEMI, acute pericarditis, aortic dissection (more constant pain)
MSK - usually worse on movement rather than exercise, may be local tenderness. Muscle strain, inflammation of the cartilage in the ribs
GI - GORD - burning pain, worse on lying down and after meals however exercise may aggravate pain, acute cholecystitis, acute gastritis, oesophageal spasm
Resp - pneumonia, pneumothorax, pleurisy (pleuritic chest pain worse on breathing in)
What management is needed for stable angina
- Explain diagnosis and implications
- GTN spray - use as instructed, 2nd dose if not eased after 5 mins, 3rd dose if not eased after extra 5 mins, 5 mins after 3rd dose if not eased ring 999
- Beta blocker/calcium blocker
- Aspirin
- Statin - for atherosclerosis
If beta block or calcium channel blocker not enough then add the other - DO NOT GIVE VERAPAMIL AND A BETA BLOCKER. Add amlodipine or nifedipine
if beta blocker and calcium channel blocker not working then add long acting nitrate e.g isosorbide mononitrate or Ivabradine, nicorandil
Coronary revascularisation if high risk and not controlled by drugs
Cardiac rehabilitation
Make them aware of symptoms of a MI
Reduce alcohol intake
Smoking cessation
Diet and lifestyle advice
How does unstable angina symptoms differ to stable angina
Central crushing NOT a relieved by rest or GTN spray Severe pain and new onset Prolonged angina pain at rest (more than 20 mins) Sweating Nausea Vomiting Fatigue SOB Palpitations
What management is needed for unstable angina
Angioplasty
PCI (stents)
Cardiac rehabilitation
Ticagrelor with low dose aspirin if admitted with unstable
Nitrates
Beta blockers - improve outcome and reduce severity and frequency of attacks
Calcium channel blocker - if pt cannot tolerate a beta blocker
ACE inhibitor - reduces mortality p, should be started as an inpatient
Statins - reduce occurrence of unstable angina
Morphine for pain
Anti platelet therapy - aspirin and clopidogrel
Anti thrombotic - LMWH
When should PCI be considered in unstable angina
Recurrent angina Ischaemic ECG changes Features of HF Poor LV function Haemodynamic instability PCI <6 months Previous CABG
What are the complications of unstable angina
Another episode MI carcinogenic shock Ischaemic mitral regurgitation SVT Ventricular arrhythmias
How does ivabradine work
Inhibits the funny current - If channel
this is highly expressed in the SAN
therefore reduces heart rate
What are the side effects of ivabradine
Can get bradycardia
Transient luminious phenomenon - bright spots appearing
What should be done if a patient cannot be managed on both a beta blocker and a calcium channel blocker
Refer to cardiology for PCI or CABG
and add 3 rd drug, usually long acting nitrate
Which anti-anginal drug do patients develop a tolerance to
Standard release isosorbide mononitrate
Tolernace not usually seen in modified release
