angina

Question 1

epidemiology

Answer 1

increases with age in both sexes

Question 2

risk factors (7)

Answer 2

hypertension, hyperlipidaemia, diabetes mellitus, sedentary lifestyle, obesity, smoking, Fx

Question 3

diagnosis : typical, atypical and non-angina

Answer 3

characterised by chest pain ! heavy, tight, gripping pain centrally or retrosternally and may radiate to jaw / arms / neck / teeth / back (atypical angina is 2/3 of these things and non-angina chest pain is 1/3)
visceral pain from myocardial hypoxia - will be difficult for patients to describe, often give gestures to where the pain is
what kind of pattern is the pain?
sometimes patients will deny it even as a pain but as a dull ache ..

can be worsened by cold wind ! and also after eating
only comes on for a few minutes

**
must remember to ask what exacerbates it/alleviates it
does it come on for a long time? (usually not angina if it comes on for a long time but more likely to be an MI!!)

Question 4

diagnosis : stable angina (classed)

Answer 4

class 1 - angina with strenuous activity only 
class 2 -angina during ordinary activity ie walking up a hill, with mild limitations of activity 
class 3 - angina on low levels of activity ie walking 50-100m with marked restrictions on activity 
class 4 - angina at rest or with any type of exercise

Question 5

what is revascularisation ?

Answer 5

restored perfusion of a previously ischaemic body part/organ …think stenting !

Question 6

diagnosis : unstable angina

Answer 6

angina of recent onset or sudden deterioration of stable angina, symptoms occurring frequently at rest

Question 7

diagnosis : refractory

Answer 7

patients with severe coronary artery disease

revascularisation is not possible and cannot be managed with medical therapy

Question 8

diagnosis : vasospastic/variant

Answer 8

angina that comes without provocation, usually at rest as a result of a coronary artery spasm (happens more frequently in women)

Question 9

diagnosis : microvascular

Answer 9

exercised induced angina, but have non-obstructed coronary arteries (intracoronary acetylcholine may cause coronary spasm)
good prognosis - very difficult to treat

Question 10

examination

Answer 10

• look for signs of anaemia, hyperlipidaemia, thyrotoxicosis
• need to rule out aortic stenosis (narrowing of exit of LV)
• hypertension should be identified if existing (BP)
• BMI and waist circumference

Question 11

what is thyrotoxicosis ?

Answer 11

excess thyroid hormone action at tissue level due to high levels of thyroid hormone concentrations in blood - can case hyperthyroidism

Question 12

initial investigations for suspected angina

Answer 12

full blood count 
thyroid function tests
fasting glucose
HbA1c (diabetes m)
fasting lipid profile 
glomerular filtration rate
troponin (unstable angina)
---
ECG
Echocardiogram
ambulatory ecg 
CXR

Question 13

investigations for typical/atypical/non-angina with ST changes or Q waves and also if have known CAD

Answer 13

CTCA (computed tomography coronary angiography)

Question 14

inv. for stable angina

Answer 14

via clinical assessment and/or CTCA,SPECT,stress echocardiogram, stress MRI

spect = single photon emission ct

Question 15

management of stable angina (1)

Answer 15

> patients should be informed that their prognosis is good ! (mortality = <2%)
lifestyle management should be instigated (prevention of CAD)
given short-acting nitrates for sudden onset (vasodilators)
secondary prevention

Question 16

management of stable angina (2)

Answer 16

> prescribe beta blockers OR calcium channel blockers
>if not tolerated or contraindicated, then prescribe long acting nitrates ie ivabradine, nicorandil, ranolazine
>if still symptomatic then prescribe both beta blockers and calcium channel blockers or switch from beta to calcium
»if still symptomatic on both then consider revascularisation (coronary artery bypass grafting/percutaneous coronary intervention)

Question 17

percutaneous coronary intervention - PCI

Answer 17

the process of dilating a coronary artery stenosis by introducing a inflatable balloon and a metallic stent into arterial circulation via femoral/brachial/radial artery
>bare metal stents have a higher incidence of restenosis compared to drug eluting stents
-may need emergency CABG
-MI may occur and stroke and heart failure are also a risk the same goes for CABG
-renal failure
-infection
>need anti-lately drugs and anticoagulants as well
>catheter to ostium of artery

Question 18

coronary artery bypass grafting - CABG

Answer 18

when autologous veins OR arteries are anastomosed (joined together) to the ascending aorta and to native coronary arteries distal to the area of stenosis
big surgery !!
-MI is a real possibility (3%)
-infection

Question 19

pharmacological therapy in stable angina !! (PTSA!!) - vasodilators (1)

Answer 19

short-acting !
glyceryl trinitrate: >0.3-1.0mg sublingual and 2.0-3.0 buccal
>prophylaxis and treatment of angina (rapid onset)
>repeat after 5m if symptomatic
>can cause headache and flushing
isosorbide mononitrate: >10-60mg twice daily (2d)
>prophylaxis
>can cause headache and flushing
>contraindicated with phosphodiesterase type 5 inhibitors

Question 20

PTSA!! - vasodilators ivabradine

Answer 20

long-acting !
ivabradine : 2.5-7.5mg 2d
>inhibits pacemaker funny current in SA node
>use in sinus rhythm
>can cause bradycardia and phosphenes
>contraindicated with sick sinus syndrome, AV block

Question 21

PTSA!! - vasodilators nicorandil

Answer 21

5-30mg 2d
activates ATP sensitive potassium channels and has nitrate properties
can cause headache, flushing, oral ulceration

Question 22

PTSA!! - vasodilators ranolazine

Answer 22

375-750mg 2d
inhibits late sodium channels into cardiac cells
can cause dizziness, constipation, lengthened QT

Question 23

PTSA!! - beta blocker bisoprolol

Answer 23

2.5-10mg 2d
inhibits Badrenoceptors, reduces HR and BP and myocardial oxygen consumption
!! caution !! with COPD, acute heart failure, AV conduction
can cause, fatigue, peripheral vasoconstriction, sexual dysfunction, bronchospasm

Question 24

PTSA!! calcium channel blocker verapamil

Answer 24

phenylalkylamine
80-120mg 3d
inhibit calcium channels in myocardium, cardiac conductive tissue and vascular smooth muscle
can cause constipation

Question 25

PTSA!! calcium channel blocker diltiazem/verapamil/amlodipine

Answer 25

benzothiapines
60-120mg 3d
both diltiazem and verapamil are contraindicated in severe bradycardia, LV failure w pul. congestion and AV block

amlodipine - dihydropyridines
5-10mg 1d
can cause ankle oedema and tachycardia

Question 26

PTSA!! event reducing anti platelet

Answer 26

aspirin - 75-100mg 1d

clopidogrel - 75mg 1d

Question 27

PTSA!! event reducing ACE inhibitor or ARB

Answer 27

enalapril 10mg 1d
for hypertension heart failure chronic kidney disease

**
ACE = angiotensin converting enzyme
ARB = angiotensin receptor blocker

Question 28

PTSA!! event reducing statins

Answer 28

atorvastatin - 80mg 1d

reduced LDL cholesterol to <1.8mmol/L

Question 29

differential diagnosis of chest pain

Answer 29

GI tract: - can often be typical -
acid reflux, provoked by food -
peptic ulcer pain -
oesophageal spasm -
biliary colic
Musculoskeletal pain:
injury
nerve root pain
Pericarditis: often relieved by posture
Pleuritic pain: exacerbated by breathing, focal
MI: sweating, nausea/vomit, angor animi ! severe !
ongoing pain despite being on more than 10mg of morphine
PE: dull, breathlessness (perhaps pleuritic)
Dissection of the aorta: excruciating pain, severe then eases - tearing of the aortic wall, haemorrhage etc

Question 30

relation to CAD

Answer 30

if you have angina then that is a clinical diagnosis of CAD

can get CAD without angina but not angina without CAD