Angina pectoris

Question 1

Definition

Answer 1

This is an oppressive retrosternal discomfort that radiates to the arms, jaw and throat.

If unstable, it is considered a pre-myocardial infarct.

Question 2

Management of stable angina

Answer 2

Attend to any risk factors

If inactive, take on an activity such as walking for 20 mins a day

Regular exercise to the threshold of angina

Relaxation program

Avoid precipitating factors

Don’t excessively restrict lifestyle

Question 3

Medical treatment, The acute attack

Answer 3

Glyceryl trinitrate 600 mcg tab or 300 mcg (1/2 tab) SL or

GTN SL spray: 1–2 sprays; rpt after 5 mins if pain persists (max. 3 doses) or

ISD 5 mg SL; rpt every 5 mins (max. 3 doses) or

Nifedipine 5 mg capsule (suck or chew), if intolerant of nitrates or

Aspirin 150 mg (o)

Advise that if no relief after 2–3 tabs, get medical advice.

Avoid nitrates if s. phosphodiesterase inhibitors used for ED in past 1–5 d.

Question 4

Medical treatment, Mild stable angina

Answer 4

Angina that is;

• predictable
• precipitated by more stressful activities
• relieved rapidly

Aspirin 150 mg (o)/d (use clopidogrel 75 mg (o)/d if intolerant)

GTN (SL or spray) prn (use early)

• Consider a beta-blocker or long-acting nitrate or nicorandil

Question 5

Medical treatment, Moderate stable angina

Answer 5

Regular predictable attacks precipitated by moderate exertion

As mild stable angina, plus

Beta-blocker, e.g.

• atenolol 50–100 mg (o) once/d or
• metoprolol 25–100 mg (o) once/d
• starting with the lowest dose and increasing as necessary

GTN (ointment or patches) daily (12–16 h only)

or

ISN 60 mg (o) SR tablets mane (12-h span)

Question 6

Mod stable angina, if not controlled

Answer 6

Add a dihydropyridine Ca-channel blocker:

• nifedipine controlled release 30–60 mg (o)/d

or

• amlodipine 2.5–10 mg (o) once/d

If Beta-blocker contraindicated, use:

• diltiazem SR 90 mg (o) bd (max. 240 mg/d) or CR 180–360 mg (o)/d,

or

• nicorandil 5 mg (o) bd, ↑ to 10–20 mg bd after 1 wk

Question 7

Persistent or refractory angina

Answer 7

Consider ivabradine but pts require specialist evaluation for suitability for a corrective procedure.

Question 8

Management of unstable angina

Answer 8

Hospitalise for stabilisation and further evaluation.

The objectives are;

1. to optimise therapy
2. give IV trinitrate and heparin
3. consider coronary angiography
4. with a view to a corrective procedure such as CABG or percutaneous transluminal angioplasty stenting.

Question 9

Discuss how to manage an attack of angina

Answer 9

1) Should sit down, take one or two puffs of angina spray and wait for the pain to subside.
2) If not gone in 5 minutes, to take another puff.
3) If still not gone after another 5 minutes, take another puff
4) If not gone after another 5 minutes then should call an ambulance.”