Angina

Question 1

What are the two main causes of angina?

Answer 1

Low myocardial oxygen supply

High myocardial oxygen deman

Question 2

For what reasons may myocardial oxygen supply be low?

Answer 2

Coronary artery disease - atherosclerosis

Severe anaemia

Question 3

For what reasons may myocardial oxygen demand be high?

Answer 3

LV hypertrophy
RV hypertrophy
Rapid tachyarrhythmias

Question 4

Why might you get LV hypertrophy?

Answer 4

hypertension
aortic stenosis
aortic regurg
Hypertrophic cardiomyopathy

Question 5

Why might you get RV hypertrophy?

Answer 5

Pulmonary hypertension

Pulmonary stenosis

Question 6

When might you need to refer a patient to a specialist in regards to angina?

Answer 6

worsening angina in patient with previously stable symptoms
new/recurrent angina when patient has history of MI or coronary revascularisation
occupational fitness assessment needed
atypical symptoms
new onset angina

Question 7

What are the main things to look at when diagnosing angina?

Answer 7

HISTORY!
character
location
radiation
duration
provocation

Question 8

What is the diagnostic challenge with angina?

Answer 8

It is usually a manifestation of coronary artery disease so need to determine whether patient has chest pain WITH flow limiting coronary obstructions or not

Question 9

How do you manage the challenge of angina diagnosis?

Answer 9

Functional testing for ischemia - stress echo

Anatomical testing for evidence of obstructive disease - CT Coronary Angiography

Question 10

What are the 3 characteristics for typical angina?

Answer 10

central chest discomfort last 5-15 mins
provoked by exertion or emotional stress
relieved by rest/nitrates

Question 11

What should be done if only 1 or less than 1 characteristics are present in the patient?

Answer 11

No diagnosis is needed

Question 12

What to do if 2 or 3 characteristics are present?

Answer 12

CTCA diagnostic testing

or functional imaging

Question 13

What are some symptom relief drugs/methods which can increase oxygen delivery?

Answer 13

increase coronary flow - nitrates, Calcium blockers, nicorandil which is a vasodilator, revascularisation

Question 14

What are some symptom relief drugs which can reduce oxygen demand through reducing heart rate?

Answer 14

beta blockers, ivabradine (newer drug)

Question 15

What drugs can be given in prevention to those who have already experienced angina?

Answer 15

aspirin
statins
(mainly those 2)
ACE inhibitors
P2Y12 receptor antagonists

Question 16

What is the main procedure that can be done to repair coronary vasculature?

Answer 16

Coronary revascularisation

Question 17

What are the main things to consider when thinking about coronary revascularisation?

Answer 17

Prognostic benefit
Repeat revascularisation
Symptomatic benefit
Coronary anatomy
Patient choice
Procedural risk - stroke, death, AMI

Question 18

What are the key assessments for chest pain?

Answer 18

How long have they had pain? (if it for 10 years or more it is unlikely to be because of the heart)
How long does pain last?
Where is it localised?
What is the pain like?
What provokes/relieves the pain?

Question 19

How is ischemia testing done?

Answer 19

Exercise to increase heart rate so that when ischemia kicks in you can carry out perfusion imaging of coronary arteries. You can then see the LV wall motion to see how the heart contracts and ischemia will mean some parts of the wall will stop contracting, finally ECG’s to look at ST segments, and history!

Question 20

What is ETT? How effective is it in comparison to CTCA?

Answer 20

Exercise Tolerance Testing, more false negatives than CTCA which is bad when you are testing for a serious disease as don’t want to miss it out

Question 21

What are the ways to reduce oxygen demand?

Answer 21

decrease heart rate
reduce LV wall tension
reduce contractility
modify energy metabolism

Question 22

What are some symptom relief drugs which can reduce oxygen demand through lowering LV wall tension?

Answer 22

beta blockers, nitrates, nicrorandil, calcium blockers, ranolazine

Question 23

What are some symptom relief drugs which can reduce oxygen demand through reducing contractility?

Answer 23

beta blockers, calcium blockers

modify energy metabolism - trimetazidine

Question 24

What are the NICE guidelines for angina treatment?

Answer 24

β blocker ± CAB (calcium channel blocker)
sublingual GTN (glyceryl trinitrate spray which works to dilate blood vessels)
aspirin, statin, ±ACE-I
lifestyle modification

Question 25

What should you do if there is no further angina after the first treatment is given?

Answer 25

No further treatment
Discuss with patient:
prognosis
 likelihood of high risk anatomy
 benefits/risks of CABG

Question 26

What should you do if after treatment there is still continuing angina?

Answer 26

Revascularisation after discussing with the MDT

Then if that does not work - coronary bypass surgery which is usually more effective.

Question 27

How is coronary bypass usually done?

Answer 27

Using saphenous vein or using internal mammary artery

Question 28

What is revascularisation?

Answer 28

It means to restore the blood supply to the coronary arteries. There is angioplasty where a balloon is used to widen the narrowed arteries or there is bypass where a vessel is taken from another part of the body and inserted to replace the damaged one.