Angina Flashcards
What are the 4 different types of angina?
- Stable = induced by effort, relieved by rest
- Unstable = occurs at minimal exertion or at rest
- Decubitus = precipitated by lying flat
- Variant = caused by coronary artery spasm
What are 3 main features of angina?
- Constricting-heavy discomfort
- Pain brought on by exertion
- Pain relieved within 5 mins of rest or use of GTN spray
1-2 features = Non anginal chest pain
2 features = Atypical angina
3 features = Typical angina
What are the clinical features of angina?
- Chest pain
- Dyspnoea
- Nausea
- Sweating
- Faintness
What characteristics make angina a less likely diagnosis?
Continuos pain associated with palpitations, dizziness or tingling
Worse with swallowing
What is the differential diagnosis of Angina?
- Acute Coronary Syndrome
- Aortic Stenosis
- Cholycystisis
- GORD
- Acute Pericarditis
- Acute Gastritis
- Hyperthyroidism
What are the risk factors of Coronary Artery Disease?
- Smoking
- Alcohol
- Hypertension
- Old Age
- Lack of exercise
- Obesity
- High cholesterol
- Family History
What are the causes of angina?
- Atheroma
- Anaemia
- Coronary artery spasm
- Small vessel disease
What is the pathophysiology of angina?
There for 2 main causes of angina:
- Atherosclerosis
- Coronary artery spasm
Pathophysiology of Atherosclerosis:
- Macrophages recruited in response to endothelial injury engulf oxidised LDLs and cholesterol, becoming foam cells
- Foam cells release growth factors that cause migration of smooth muscle cells from media to intima
- Collection of lipid filled macrophages = fatty streaks
- Smooth muscle cells release collagen, resulting in formation of fibrous cap
Factors that trigger coronary artery spasm:
- Emotional stress
- Smoking, alcohol
- Exposure to cold
- Stimulant drugs
What are the investigation in suspected Angina?
=> ECG
ST depression or T wave inversion
=> Blood tests
FBC, TFTs, U&Es, Lipids, HbA1c
=> CT coronary angiography (1st line)
=> CXR
=> Echo
What is the management of Angina?
EXACERBATING FACTORS ARE TREATED IMMEDIATELY
Stable angina management involves secondary prevention as it is usually not as severe:
- Stop smoking
- Increase exercise
- Diabetes control
- 75mg Aspirin daily
- ACE Inhibitors
IMMEDIATE SYMPTOM RELIEF GTN SPRAY:
- Ask patient to repeat dose if pain not gone within 5 mins of use
- Call ambulance if pain persists after 5 mins of second dose
ANTI-ANGINA MEDICATIONS FOR UNSTABLE ANGINA:
- B blockers or Ca antagonists used as first line
- If Ca blocker used as monotherapy, rate limiting one such as VERAPAMIL should be used. If B blocker & Ca blocker are being used, then used long acting Ca blocker
- Increase to maximum tolerated dose if initial treatment not working
- Only use dual therapy if monotherapy not working
- If patient on monotherapy cannot tolerate Ca blocker or B blocker, use:
Long acting nitrate (Eg. Isosobride Nitrate)
Ivabradine
Ranolazine (sodium channel blocker)
Nicorandil (potassium channel activator)
How is Prinzmental angina treated?
- Trigger avoidance
- Correcting low Mg
- Stop smoking
- Symptom relief with GTN spray
- Ca blockers + long acting nitrates
- Avoiding non-selective B blockers, Aspirin, Triptans
What anti-anginal medication might patients develop a tolerance to?
Isosorbide Mononitrate
What are the major side effects of nitrates?
- Hypotension
- Tachycardia
- Headaches
- Flushing
