Angina Pectoris

Question 1

ANgina

Answer 1

Reduced bloodflow - ischemia - pain

Question 2

Types of Angina

Answer 2

Stable
Unstable
Prinzemetal (Vasoplastic)

Question 3

Stable Angina

Answer 3

> 70% stenosis. Enough to supply at rest but not on exertion
always relieved by rest or glyceryl trinitrate (GTN)
Due to -
Atherosclerosis of >1 coronary arteries
Hypertrophic cardiomyopathy
High pressure -Aortic stenosis, HTN

Ischaemia to subendocardium- adenosine and bradykinin relese stimulate nerves- pain
lasts <10 mins
ST depression

Question 4

Unstable angina

Answer 4

pain at exercise and rest
From an atherosclerotic plaque rupture with thrombus occlusion
Can progress to MI
ST depression
Ischaemic T wave

Question 5

Vasoplastic Angina

Answer 5

May or may not have atherosclerosis
Ischaemia is from Coronary artery vasospasms
Transmural
treat with nitroglycerin, responds to CCB

Question 6

Stable Angina investigations

Answer 6

CTCA CT Coronary Angiography
Baseline - 
Physical Examination (heart sounds, signs of heart failure, BMI)
ECG
FBC (check for anaemia)
U&Es (prior to ACEi and other meds)
LFTs (prior to statins)
Lipid profile
Thyroid function tests (check for hypo / hyper thyroid)
HbA1C and fasting glucose (for diabetes)

Question 7

Management of stable angina

Answer 7

R – Refer to cardiology (urgently if unstable)
A – Advise them about the diagnosis, management and when to call an ambulance
M – Medical treatment
P – Procedural or surgical interventions

Question 8

M – Medical treatment for stable angina

Answer 8

GTN - for immediate relief. take twice if not stopped call ambulance
1st Line
Beta blocker - Bisoprol 5mg ( if previous MI or HF)
Calcium channel blockers - amlodipine 5mg (if previous MI no HF)

2nd line -
Nicorandil or long acting nitrate
Ranoazine
Ivabradine

Secondary prevention
Statins - Atovarstatin
Aspirin 75mg
ACE inhibitors

Question 9

Classes of Stable Angina

Answer 9

Class 1 – No angina with ordinary activity. Angina with strenuous activity
Class 2 – Angina during ordinary activity eg walking uphill, upstairs rapidly. Mild limitation of activities
Class 3 – Angina with low levels of activity eg ; walking 50-100 yards on the flat, climbing one flight of stairs. Marked restriction of activities.
Class 4 – Angina at rest or with any level of exercise

Question 10

P – Procedural or surgical interventions of Stable Angina

Answer 10

Percutaneous Coronary Intervention (PCI) with coronary angioplasty
Coronary Artery Bypass Graft (CABG)

Question 11

Making a Diagnosis of ACS

Answer 11

◉If there is ST elevation or new left bundle branch block the diagnosis is STEMI.

◉If there is no ST elevation then perform troponin blood tests:

◉If there are raised troponin levels and/or other ECG changes (ST depression or T wave inversion or pathological Q waves) the diagnosis is NSTEMI

◉If troponin levels are normal and the ECG does not show pathological changes the diagnosis is either unstable angina or another cause such as musculoskeletal chest pain

Question 12

ACS Symptoms

Answer 12

Central, constricting chest pain associated with:

Nausea and vomiting
Sweating and clamminess
Feeling of impending doom
Shortness of breath
Palpitations
Pain radiating to jaw or arms
Symptoms should continue at rest for more than 20 minutes. If they settle with rest consider angina. Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”.

Question 13

ECG Changes in Acute Coronary Syndrome

Answer 13

STEMI:

ST segment elevation in leads consistent with an area of ischaemia
New Left Bundle Branch Block also diagnoses a “STEMI”
NSTEMI:

ST segment depression in a region
Deep T Wave Inversion
Pathological Q Waves (suggesting a deep infarct – a late sign)

Question 14

alternative causes of raised troponins:

Answer 14

Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism

Question 15

ACS investigations

Answer 15

Troponins
Physical Examination (heart sounds, signs of heart failure, BMI)
ECG
FBC (check for anaemia)
U&Es (prior to ACEi and other meds)
LFTs (prior to statins)
Lipid profile
Thyroid function tests (check for hypo / hyper thyroid)
HbA1C and fasting glucose (for diabetes)
Plus:

Chest xray to investigate for other causes of chest pain and pulmonary oedema
Echocardiogram after the event to assess the functional damage
CT coronary angiogram to assess for coronary artery disease

Question 16

Acute STEMI Treatment

Answer 16

Patients with STEMI presenting within 12 hours of onset should be discussed urgently with local cardiac centre for either:

Primary PCI (if available within 2 hours of presentation)
Thrombolysis (if PCI not available within 2 hours)

Question 17

Acute NSTEMI treatment

Answer 17

BATMAN

B – Beta-blockers unless contraindicated Bisoprolol 2.5mg od

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

M – Morphine titrated to control pain

A – Anticoagulant: Fondaparinux (unless high bleeding risk)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Question 18

GRACE Score to assess for PCI in NSTEMI

Answer 18

This scoring system gives a 6-month risk of death or repeat MI after having an NSTEMI:

<5% Low Risk
5-10% Medium Risk
>10% High Risk
If they are medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.

Question 19

Complications of MI (Heart Failure DREAD)

Answer 19

D – Death

R – Rupture of the heart septum or papillary muscles

E – “Edema” (Heart Failure)

A – Arrhythmia and Aneurysm

D – Dressler’s Syndrome

Question 20

Secondary Prevention Medical Management (6 As) after PCI

Answer 20

Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Dual antiplatelet duration will vary following PCI procedures depending on the type of stent that was inserted. This is due to a higher risk of thrombus formation in different stents.

Question 21

Secondary Prevention Lifestyle

Answer 21

Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation (a specific exercise regime for patients post MI)
Optimise treatment of other medical conditions (e.g. diabetes and hypertension)

Question 22

Dressler’s Syndrome

Answer 22

This is also called post-myocardial infarction syndrome. It usually occurs around 2-3 weeks after an MI. It is caused by a localised immune response and causes pericarditis (inflammation of the pericardium around the heart). It is less common as the management of ACS becomes more advanced.

It presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely a pericardial tamponade (where the fluid constricts the heart and prevents function).

A diagnosis can be made with an ECG (global ST elevation and T wave inversion), echocardiogram (pericardial effusion) and raised inflammatory markers (CRP and ESR).

Management is with NSAIDs (aspirin / ibuprofen) and in more severe cases steroids (prednisolone). They may need pericardiocentesis to remove fluid from around the heart.

Question 23

Treatment – STEMI/New LBBB

Answer 23

reperfusion within 12 hrs of onset of symptoms

PCI + stent
Fibrinolytic therapy
Rescue Angioplasty

After-
BB
ACE /ARBs
Statins

Question 24

Treatment of Unstable Angina and NSTEMI

Answer 24

To prevent new thrombus formation : 
LMWH – subcut e.g. Fondaparinux
Aspirin 75mg daily after loading dose (300mg)
Clopidogrel 75mg daily after loading dose (300mg)
To reduce myocardial oxygen demand:
Beta blocker
Consider IV/buccal nitrate
Treat arrythmias/heart failure promptly

Question 25

Pharmacological treatment of stable angina pectoris

Answer 25

◉GTN for acute episodes
◉1st line
BB - if previous MI or HF
BB/rate limiting CCB - MI no HF
CCB - Uncontrolled Hypertension, Vasospastic angina

◉If combi needed - use BB and non heart rate limiting!
CCB (DHP e.g amlodipine/difedipine)

◉Still angina - use 2nd line as mono or comb therapy
Long acting Nitrate or nicorandil
Ranolazine
Ivabradine - if rate control not achieved

Consider revascularisation b4 adding a 3rd agent

Question 26

SE GTN

Contraindications

Answer 26

Headaches, dizziness, hot flushing, nausea

Systemic hypotension, Viagra (sildenafil), Aortic stenosis, hypertrophic cardiomyopathy

Question 27

Other name for Beta blockers

Answer 27

Sympatholytics
Adrenergic antagonists
-olol

Question 28

Uses of BB

Answer 28

Angina
Arrythmias
HTN
Heart failure
MI and ischaemia
Topically for glaucoma and migrane prophylaxis

Question 29

B1 receptors

Answer 29

Heart 
> chronotropy and inotropy
and kidneys
> rate of AV conduction
stim juxtaglomerular cells > renin production

Question 30

SE

Answer 30

Bradycardia

Question 31

BB generations and targets

Answer 31

1st gen - Propranolol - non selective B1, B2
HTN, Arrhythmias and Angina
B2 blocking - lead to bronchoconstriction

2nd gen - Atenolol, Bisoprolol - selective B1

3rd gen - Labetalol - both selective and non selective - a1,b1 causing vasodilation
Nebivolol - b1 selective- vasodilator via NO release
Betaxolol - vaso via blocking CC - topically for intraocular pressure

Question 32

CCB examples, USes and SE

Contraindications

Answer 32

VERY NICE DRUGS - Verapamil, Nifedipine, Diltiazem

Question 33

CCB MOA

Answer 33

Vasodilator(systemic) and Cardio depressant
◉Cardioselective - V and D - vasodilation

◉Smooth muscle selective - dihydropyridines (-pine)
Dilate coronary arteries - Vasospastic, Printzmetal angina. Peripheral vasodilation
Potential reflex > HR, chronotropy and o2 demand

Long acting DHPs - safer anti htn, reduced reflex response - Amlodipine and Nefidepine

Question 34

ACS Protocol

Answer 34

History and examination
ECG for risk stratification - every 15 minutes until pain free then @1hr & 4hrs after pain
◉ST elevation - STEMI
>2mm in 2 leads V1-V6 or LBBB
➡ MONA + anti emetic (metoclopramide)
Call Cathlab 
assess for reperfusion (<12hrs) or medical management
➡PCI or Fibrinolysis (if PCI not avail in 2hrs)
PCI - Prasugrel (Clopidogrel) with Aspirin
UH for radial access
Fibrinolysis ( ases bleeding disorders 1st)
Antithrombin - Tenecteplase 
adjuct therapy wth IV heparin or LMWH (fondaparinux) to maintain patency
Ticagrelor  (Clopidogrel) with aspirin 
secondary PCI
➡medical management
Ticagrelor  (Clopidogrel) with aspirin
Cardio assessment
◉ST depression or T-inversion
>0.5mm dep
>2mm inversion
➡ MONA + anti emetic (metoclopramide)
BATMAN
◉Normal
chest pain resolved or non diagn ECG
➡ restratify with Trop and TIMI

BP both arms
IV access and Bloods (Troponins, FBC, LFTs, U&Es, CRP, Coagulation screen, CXR, Lipids)

Question 35

Statins

Answer 35

HMG - CoA Reductase Inhibitors

Inhibit enzyme HMG-CoA reductase so Hepatocyte HMG-CoA is not transformed to Mevalonic acid (cholesterol precusor)

Question 36

SE of statins

Answer 36

Raised liver enzymes
> risk of liver toxicity
myopathy
rhabdomyolysis

Question 37

Septic 6

Answer 37

blood cultures, check full blood count and lactate, IV fluid challenge, IV antibiotics, monitor urine output and give oxygen.