Angina and ACS Flashcards
3 Features of Angina
- Chest pain radiating to jaw, neck, shoulders or arms
- Symptoms brought on by exertion
- Symptoms relieved by 5mins rest or GTN spray
All 3= Typical
2= Atypical
0-1= Non-Anginal
Precipitants of angina
Emotions, cold weather, heavy meals
Associated symptoms of angina
Dyspnoea, nausea, sweatiness, faintness
Features that make angina less likely
Pain that is continuous, pleuritic or worse with swallowing.
Pain associated with palpitations, dizziness or tingling
Causes of angina
Atheroma
Rarely: anaemia, coronary artery spasm, AS, tachyarrythmias, HCM, arteritis
Types of angina
Stable- induced by effort, relieved by rest. Good prognosis
Unstable (crescendo)- Increases in frequency or severity, occurs on minimal exertion or at rest; associated with increased risk of MI
Decubitus angina- precipitated by lying flat
Variant (Prinzmental)- caused by coronary artery spasm
Angina Ix
ECG- normal may show ST depression, flat or inverted T waves, signs of past MI
Bloods- FBC, U/E, TFTs, lipids, HbA1c- reasons? see PUK
Consider echo and CXR
ECG in angina
Normal does not rule out angina, may show signs of ischaemic changes
Changes on resting ECG consistent with CAD include
-Pathological Q waves
-Left bundle branch block
-St-segment and T wave abnormalities
Angina epidemiology
More common F/M?
Ethnicities?
More common in South Asian population
Black Afro-Caribbean people have reduced risk
Higher in lower socio-economic groups
Angina risk factors
Increasing age, male gender, CV RF, smoking, diabetes, hypertension, dyslipidaemia, FH of premature CAD, Hx of CAD
Angina Differentials
MI- longer than 5mins not relieved by rest
Prinzmetal’s- occurs at rest and exhibits circadian pattern, most episodes occurring early in morning
Acute pericarditis- constant, aggravated by inspiration, lying flat, swallowing and movement
MSK pain- worse on movement
Reflux
Pleuritic
Dissection
Gallstones
If estimated likelihood of CAD greater than 90%?
Further investigation unnecessary, manage as angina
Arrange blood tests for conditions that exacerbate angina
Symptoms suggesting ACS
Pain at rest (may occur at night)
Pain on minimal exertion
Angina that seems to be progressing repidly
- refer urgently
Ix confirmed CAD in context of angina
Treat as stable angina
If suspected that pain is not caused by ischaemia, offer non-invasive functional imaging or refer for exercise testing
If likelihood of CAD between 10-90%?
Arrange bloods for conditions that exacerbate angina
Consider aspirin if likely to be stable angina
If estimated likelihood of CAD is 61-90%?
Offer invasive coronary angiography
If estimated likelihood of CAD is 30-60%?
Offer non-invasive functional imaging for myocardial ischaemia
-MPS, stress echo, first pass contrast enhanced MR perfusion
If estimated likelihood of CAD is 10-29%
Offer CT calcium scoring
If estimated likelihood of CAD is less than 10%
Consider other causes
Pharmacological management of angina
- GTN symptom relief
- Aspirin (clopidogrel if contra)
- Statins
- Beta blocker or CCD
- Then switch or combine
- If one contra-indicated add a long acting nitrate, ivabradine or ranolazine
- If both contra-indicated monotherapy with long acting nitrate, ivabradine or ranolazine
- ACEi if diabetic
Coronary revascularisation
For those at high risk and those who have failure to be controlled
Patients who do not respond to treatment
- Explore patients understanding
- Establish how symptoms affect quality of life
- Review diagnosis and consider other causes
- Explain how the patient can self manage
- Explain role of psychological factors in pain
Angina advice to patient
Reduce CV RFs (smoking, diet, physical activity, alcohol)
Sexual activity for angina?
If patient can climb up and down two flights of stairs briskly without symptoms, sexual activity unlikely to precipitate episode of angina
If sexual activity does precipitate angina?
GTN spray immediately before intercourse
Contraindication to GTN spray?
Phosphodiesterase inhibitors
Complications of angina
- Cardiovascular complications
- Anxiety and depression
- Reduced general health
Prognosis
Annual mortality 1.2-2.4%
ACS RF
- NM for atherosclerosis: age, male, FH, premature menopause
- M for atherosclerosis: smoking, DM, hypertension, dyslipidaemia, obesity, inactivity
ACS Presentation
- STEMI and NSTEMI may be indistinguishable
- Prolonged anginal pain at rest
- New onset angina limiting daily activities
- Recent destabilisation of angina
- Post MI angina
ACS chest pain
Associated with sweating, nausea, vomiting, fatigue, SoB, palpitations
-Some patients (particularly elderly and diabetics) may not have chest pain
Should response to GTN be used to diagnose ACS
No
ACS Differentials
- CV: acute pericarditis, myocarditis, aortic stenosis , aortic dissection, PE
- Resp: pneumonia, pneumothorax
- GI: oesophageal spasm, GORD, acute gastritis, cholecystitis, acute pancreatitis
- MSK
ACS Ix
- ECG
- Cardiac Enzymes
- FBC
- Blood glucose (hyperglycaemia common and powerful predictor)
- Echo
- CXR (alternative diagnoses)
- Cardiac MRI
- Coronary angiography gold standard
Within first six hours which is superior for detection of MI?
Troponins or CK-MB?
Troponins
Timeline of troponin
Detectable 3-6 hours after infarction, peak at 12-24 hours, remains raised for 14 days
Test troponins when
Between 6-12 hours after onset of pain
For ACS, after aspirin and antithrombin therapy have been offered, do what?
Risk assessment, GRACE score
Management of NSTEMI/unstable angina
- Oxygen
- Nitrates: if sublingual ineffective; IV or buccal
- If pain continues morphine
- Aspirin 300mg
- If high risk (GRACE, secondary criteria, rise in troponin)
- LMWH
- IV nitrate
- Beta blockers
- If high risk: Glycoprotein IIb/IIa inhibitors
Management of STEMI
-Oxygen
-Morphine
-Aspirin+ticagrelor
-PCI or thrombolytic drug
-If PCI not available within 90mins, thrombolytic drug with any heparin
-Nitrates; if ineffective, IV
-Beta blockers
-ACE inhibitors
Monitor hyperglycaemia
Long-term management of STEMI
Discharge with
- Aspirin
- Clopidogrel (if intolerant prasugrel or ticagrelor, or warfarin if low risk of bleeding)
- Beta blockers
- ACEi
- Nitrates
- Statins
Which troponins are most specific to the heart?
I and T
Causes of raised troponin
MI, Right ventricular strain (from massive PE), sepsis, renal failure, burns SAH
-change in troponin level is often more important than actual troponin level
