Angina

Question 1

What is angina?

Answer 1

Chest pain/discomfort resulting from ischaemia (a supply/demand issue)

Usually results from atherosclerosis to one or more coronary artery

Can be stable = occurring only on exertion (quantify how much); or unstable = occurs at rest

Question 2

What is the epidemiology of angina?

Answer 2

8% of men 3% women; 55-64; south Asian origin; low socioeconomic groups

FHx; smoking; DM; metabolic syndrome; hyperlipidaemia; HTN; obesity; lack of exercise

Aortic stenosis; hypertrophic cardiomyopathy

Question 3

How does angina present?

Answer 3

Central, constricting chest pain, radiation to neck/shoulder/jaw/arms, precipitated by exertion, relieved by rest or GTN (c.5mins)

Question 4

How do you investigate angina?

Answer 4

12 lead ECG:

• Some ischaemic changes but not always present
• e.g. Pathological Q waves, LBBB, ST/T wave inversion/flattening

FBC: anaemia

U+E: baseline

Fasting/random BM: DM

Fasting cholesterol and triglycerides: ratio of total:HDL

LFTs: before starting statins

TFTs: thyrotoxicosis

Troponin: rule out MI

Echo: structural disease

Question 5

What further testing might be done by cardiology?

Answer 5

ECG exercise testing
- But does not exclude a Dx of CAD

MR coronary angiography:
- Similarly, may not exclude CAD

Invasive coronary angiography

CT calcium scoring

Question 6

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Answer 6

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Question 7

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Answer 7

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Question 8

How do you manage angina?

Answer 8

Symptoms:

0) Stop what you’re doing and rest - use GTN, take a second dose after 5mins and a 3rd dose 5 mins after, then after another 5 mins - ambulance
1) GTN spray PRN + beta blocker OR rate-limiting CaB - to max dose
2) Then add:
- Long acting CaB e.g. nifedipine MR (stop rate limiting CaB)
3) Then add:
- Isosorbide mononitrate or nicrorandil
- Once pt is waiting for CABG

If CaB is used as monotherapy - should be a rate-limiting one e.g. verapamil or diltiazem - but should not be prescribed together with BBs (but dihydropyridine CaBs e.g. -pines can be)

If taking SR isosorbide:
- asymmetric dosing interval to maintain a daily nitrate-free time of 10-14hrs to minimise development of nitrate tolerance

Other:

• Aspirin 75mg (or clopi of contra)
• Statin 20mg (atorva)
• ACE-i - if also have DM