Angina Pectoris

Question 1

How common is it?

Answer 1

• 8/3% men/women 55-64 have or have had angina.

- 14/8% men/women 65-74 have or have had angina.

Question 2

Who does it affect?

Answer 2

• Elderly, men more at risk than women. South Asians at increased risk, black caribbeans at reduced risk. In men and women risk increased in lower socioeconomic groups.

Question 3

What causes it?

Answer 3

• Results from demands of the myocardium being unable to be met by blood supply. This usually implies narrowing of one of more coronary arteries and it tends to occur at times when the heart has to do more work, eg exercise or emotional stress.

Question 4

What risk factors are there (and how can they be

reduced)?

Answer 4

• Family history, smoking, diabetes mellitus, metabolic syndrome, hyperlipidaemia, hypertension, obesity and lack of exercise. - Cardiac abnormalities, especially outflow obstruction such as aortic stenosis or hypertrophic obstructive cardiomyopathy.

Question 5

How does it present?

Answer 5

• Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms. - Precipitated by physical exertion. - Relieved by rest or GTN in about 5 minutes.

Question 6

Conditions that present similarly?

Answer 6

• MI – if pain lasts more than 5 minutes and is not relieved by rest.
• Acute pericarditis – tends to be more constant pain, aggravated by lying flat, inspiration, swallowing and movement.
• Musculoskeletal pain – deep inspiration and rotation may aggravate pain and may be areas of local tenderness.
• GOR - often a burning pain, most common on lying down and after meals. Exercise may aggravate pain – improved by antacids and course of PPIs.
• Pleuritic chest pain – pain on inspiration. May be mucus or haemoptysis.
• Aortic dissection – causes a more constant pain.

Question 7

How would you investigate the patient?

Answer 7

• Similar to acute MI.
• Fasting blood glucose if not known to be diabetic. Fasting blood cholesterol and triglycerides.
• Baseline LFTs before starting statins.

Question 8

What treatments would you consider?

Answer 8

• Issue patient with GTN spray to be used when an angina attack occurs.
• Offer beta-blocker or calcium channel blocker as first line treatment.
• If a patient’s symptoms are not adequately controlled on one drug and the other is either contra-indicated or not tolerated, consider adding: A long-acting nitrate, ivabradine (a selective inhibitor of sinus node pacemaker activity), nicorandil, ranolazine (reduces myocardial ischaemia by acting on intracellular sodium currents).
• Aspirin should be started.
• ACE inhibitor should be started in patients with angina and diabetes.
• Statins should be prescribed.