Angina and IHD

Question 1

What are the features that characterize typical chest pain?

Answer 1

Constricting discomfort affecting the chest, arms or neck

Symptoms precipitated by exertion

Symptoms relieved within 5 minutes use of GTN or rest

All three features must be present for typical chest pain.

Question 2

How many features must be present for atypical chest pain?

Answer 2

2 out of 3 features

Atypical chest pain satisfies two of the three defining features.

Question 3

What defines non-anginal chest pain?

Answer 3

1 or 0 out of 3 features

Non-anginal chest pain shows minimal alignment with the typical angina features.

Question 4

Baseline investigations if patient presents with chest pain

Answer 4

FBC
ECG
CXR

Question 5

How is significant coronary artery disease diagnosed?

Answer 5

By either 70% stenosis of 1 major coronary artery or 50% stenosis of the left main coronary artery.

Question 6

What should be done if CTCA is inconclusive or if the patient already has a known diagnosis of CAD?

Answer 6

Non-invasive functional imaging to demonstrate reversible/inducible ischaemia.

Question 7

List four methods of non-invasive functional imaging.

Answer 7

• Cardiac MRI (+ stress - dobutamine/exercise)
• Myocardial perfusion scan with SPECT
• Stress echocardiography
• Exercise ECG – only if known coronary artery disease

Question 8

What confirms a diagnosis of stable angina?

Answer 8

Evidence of significant CAD on CTCA or reversible myocardial ischaemia on non-invasive functional imaging.

Question 9

First line investigation for angina

Answer 9

CT coronary angiography

Question 10

Second line investigation for angina

Answer 10

Non invasive functional imaging

Question 11

Third line investigation for angina

Answer 11

Invasive coronary angiography

Question 12

Basic initial management for angina

Answer 12

statin
aspirin 75mg OD
GTN - if angina persists after 2 dose - call 999
ACEi - if DM, HTN, HF, CKD, MI
consider SGLT2i in diabetes

Question 13

First line management for angina

Answer 13

beta blocker (bisoprolol) OR calcium channel blocker (rate limiting CCB - verapamil, diltiazem)

titrate to maximum tolerated dose

Question 14

First line management for angina in asthmatic patient

Answer 14

rate limiting calcium channel blocker - verapamil or diltiazem

Question 15

Second line management for angina

Answer 15

DUAL THERAPY - beta blocker AND calcium channel blocker (long acting dihydropyridine - amlodipine, MR nifedipine/felodipine)

Question 16

Why should you not co-prescribe a beta blocker and rate limiting CCB?

Answer 16

risk of complete heart block, severe bradycardia and HF

Question 17

If patient is contraindicated on second line drugs, or on monotherapy - then which medications can be added?

Answer 17

long acting nitrate - isosorbide mononitrate

ivabradine

nicorandil

ranolazine

Question 18

Third line management for angina

Answer 18

refer to cardiology +/- revascularisation if required (PCI/CABG)

only consider adding a 3rd drug whilst awaiting specialist review

Question 19

When is CABG preferred over PCI?

Answer 19

patient is diabetic, >65yrs, has triple vessel disease

Question 20

MOA of nitrates

Answer 20

induces NO release by smooth muscle

this increases cGMP

results in decreased intracellular Ca2+ levels

leading to vasodilation

Question 21

side effects of nitrates

Answer 21

hypotension
tachycardia
flushing
headaches
reflux

Question 22

MOA of ivabradine

Answer 22

inhibits funny current in SA node which reduces HR

Question 23

side effects of ivabradine

Answer 23

visual changes - Luminous phenomena

bradycardia

peripheral oedema (ankle swelling)