Angina Pectoris

Question 1

What is the criteria for scoring angina?

Answer 1

1. Constricting or heavy discomfort of the chest, jaw, neck, shoulders or arms (1 point)
2. Symptoms brought on by exertion (1 point)
3. Symptoms relieved within 5-10 minutes by rest or GTN spray (1 point)
   3 points = typical angina/2 points = atypical angina/0-1 point = non-angina chest pain

Question 2

What is the aetiology of angina?

Answer 2

Atheromatous plaques leading to obstruction in coronary blood flow commonly. Imbalance between myocardial oxygen supply and demand. Results in ischemia. Patients can predict the amount of exercise which precipitates angina.

Question 3

What are the four types of angina?

Answer 3

1. Stable - atherosclerotic plaque, induced by effort and relieved by rest and GTN
2. Unstable - increasing frequency or severity, occurs on minimal exertion, risk of MI
3. Decubitus - precipitated by lying flat
4. Variant (prinzemetal) - caused by coronary artery vasospasm

Question 4

What are the risk factors for coronary artery disease?

Answer 4

Advanced age, smoking, hypertension, hyperlipidaemia, isolated low HDL, diabetes mellitus, inactivity, obesity, family history of coronary artery disease, male, illicit drug use.

Question 5

How do you investigate suspected angina?

Answer 5

1. Presence of symptoms and risk factors
2. FBC (severe anaemia), fasting lipids, fasting glucose, TFTs.
3. Resting ECG - often normal
4. Echo/angiography - complex patients with refractory or severe angina

Question 6

What is the lifestyle and prophylactic management of angina?

Answer 6

1. Smoking cessation, exercise, dietary advice, optimise hypertension and diabetes control.
2. 75mg aspirin OD indefinitely (prevent ACS)
3. Assess hyperlipidaemia, consider ACEi if diabetic.

Question 7

What are the medications used to treat angina?

Answer 7

1. Anti-anginal medication - beta blocker first line, calcium channel blocker second-line (atenolol 50mg BD/bisoprolol 5-10mg OD).
2. PRN symptom relief - GTN spray or sublingual tablets
3. Consider adding isosorbide mononitrate (long-acting), ivabradine or nicorandil if there is failure to control symptoms

Question 8

What is the advice given about administration of GTN spray and what are the side effects?

Answer 8

1. Repeat dose if no relief within 5 mins, call ambulance if pain persists 5 mins after second dose.
2. Headaches, hypotension