Angina and ACS

Question 1

What is stable angina?

Answer 1

episodes of reversible imbalance between myocardial oxygen supply and demand.
- usually induced by exercise, emotion or stress
- is relieved by rest or sublingual GTN

associated with transient substernal chest discomfort/pain

Question 2

What is the difference between stable and unstable angina?

Answer 2

stable angina
- symptoms >2months without changes in severity, character or triggering circumstances
- absence of features of unstable angina

unstable angina
- pain occurs at rest/unpredictably
- is not relieved by rest or sublingual GTN

Question 3

What are causes of imbalance between myocardial oxygen supply and demand?

Answer 3

atheromatous plaque
coronary vasospasm
left ventricular hypertrophy
systemic diseases
- anaemia, thyrotoxicosis
haemodynamic factors
- tachycardia, hypertension
microvascular dysfunction

Question 4

What is atherosclerosis?

Answer 4

build up of lipids and fatty substances causing thickening within walls of large and medium size arteries

Disease where the inside of the artery narrows due to build up of plaque:
1 - Endothelial dysfunction (from hypertension or cholesterol)
2 - Formation of lipid layer or fatty streak within the intima
3 - Increased migration of leukocytes and smooth muscle cells into the vessel wall
4 - Foam cell formation
5 - Degradation of extracellular matrix

Question 5

What is stenosis?

Answer 5

narrowed arteries/blood vessels

stenosis of >70% can result in stable angina due to inability to adequately increase coronary blood flow with exercise.

Question 6

What are the symptoms of typical angina pain, atypical angina pain and non-angina pain?

Answer 6

typical angina pain
- central/left-sided chest ‘tightness’ which may or may not radiate to the arm/jaw
- provoked by predictable and reproducible level of physical exertion or stress
- relieved with rest or glyceryl trinitrate

atypical angina pain
- 2 of above characteristics

non-angina pain
- 1 or none of above characteristic

Question 7

What are the classes of angina severity?

Answer 7

Class I
- ordinary activity does not cause angina

Class II
- slight limitation on ordinary activity

CLass III
- marked limitation on physical activity

Class IV
- inability to carry out any physical activity without discomfort

Question 8

What are the non-modifiable and modifiable risk factors for stable angina?

Answer 8

non-modifiable
- age, male sex, family history of premature coronary artery heart disease

modifiable
- smoking, inactivity, obesity, stress, hypertension, hyperlipidaemia and diabetes

Question 9

What are tests that can be done to investigate stable angina?

Answer 9

blood tests
- glucose, lipids, full blood count, thyroid function tests, Hb1Ac
ECG
CXR
echocardiography

CT coronary angiography
functional stress tests
- MRI perfusion scan
- stress echocardiography

coronary angiography

Question 10

How can angina be managed?

Answer 10

symptom control
- restore oxygen supply/demand
- glyceryl trinitrate

secondary prevention
- manage risk factors
= exercise, smoking cessation, diet
- optimise co-morbidities
- pharmacological treatments

revascularisation
- stenting
- bypass surgery

Question 11

What are pharmacological treatments for angina relief? What are the side effects?

Answer 11

glyceryl trinitrate
- vasodilator
= prodrug which is metabolised to nitric oxide

side effects
- headaches, hypotension, flushing

Question 12

What are pharmacological treatments for angina prophylaxis?

Answer 12

first line
- beta blockers = bisoprolol, propranolol
- calcium channel blockers = diltiazem, verapamil

second line
- long acting nitrates = isosorbide mononitrate
- nicorandil
- ranolazine
- ivabradine

Question 13

What is stenting? What are the requirements?
What is coronary artery bypass surgery (CABG)

Answer 13

stenting
– putting a stent in one of the arteries = a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open
- require dual anti-platelet therapy for at least a year after drug elating stent

bypass surgery
- diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart

Question 14

What is acute coronary syndrome?

Answer 14

also known as a heart attack/myocardial infarction
- term used to describe a range of conditions

• usually caused by a blockage of a major coronary artery
• due to rupture atherosclerotic lesion within the vessel wall, causing thrombosis within the lumen
  = prevents blood flow to the heart muscle, resulting in myocardial cell damage

Question 15

What are the types of acute coronary syndrome?

Answer 15

unstable angina

Non ST-elevation Myocardial Infarction (NSTEM)

ST-elevation Myocardial Infarction (STEMI)

Question 16

What are the symptoms of ACS?

Answer 16

severe, persistent chest pain
- associated with sweatiness, nausea, breathlessness

NOT relieved by rest or sublingual GTN

Question 17

How should ACS be treated?
acute vs long term

Answer 17

acute
- morphine, oxygen, nitrates (GTN sublingual or buccal) and aspirin (loading dose given ASAP)
- anti-platelet therapy
- anti-thrombin therapy
- IV glycoprotein inhibitor
- beta blocker

long term
- dual anti-platelet therapy for 1 year - aspirin/clopidogrel
- aspirin for life
- statin = atorvastatin
- beta blocker = bisoprolol
- ACE inhibitor or ARB = ramipril, valsartan

Question 18

What is cardiac rehabilitation?

Answer 18

programme of exercise and information sessions that help patients get back to everyday life as quickly as possible

it aims to help patients:
- understand the condition
- recover from surgery or heart attack
- make lifestyle changes to improve their health and reduce the risk of a heart attack