Angina Pectoris Flashcards
What are the symptoms of angina?
- Constricting/heavy discomfort to the chest, neck, jaw, shoulder and/or arms
- Symptoms brought on my exertion
- Symptoms relieved within 5 minutes by GTN or rest
What are precipitants of angina?
- Cold weather
- Exercise
- Lying flat (Decubitus angina)
- Emotion
- Heavy meals
What is the main cause of angina?
Atheroma
What are other rarer causes of angina?
- Anaemia
- Lying flat
- Coronary artery spasm
- Aortic stenosis?
- Tachyarrythmia
- HCM - hypertrophic cardiomyopathy
- Arteritis/small vessel disease
Other than stable and unstable angina, what are the two types of angina?
- Decubitus - precipitated by lying flat
- Variant (prinzmetal) angina - coronary artery spasm
What tests should be used for investigating angina and what will be found in each test?
- ECG - usually normal exercise stress test = but may show ST depression and T wave inversion
- Angiography - cardiac CT with contrast or transcatheter angiography
- Blood tests - FBC (anaemia causing it?), U&Es, TFTs (check for thyrotoxicosis), lipids (atherosclerosis), HbA1c (diabetes is a risk factor of atheroma formation)
- Cardiac enzymes = troponin T or I should NOT be present
- Echo
- Chest X ray
Which test does NICE recommend for investigating stable angina?
- Stable angina in patient with history of IHD
- Typical and atypical angina
- Non- anginal chest pain
- Typical angina with risk factors of IHD
- Typical angina if patient has history of IHD = Exercise ECG stress test
- Typical angina and atypical angina - CT angiography
- If inconclusive, use functional imaging (chest x ray, echo, cardiac ct, cardiac mri) as 2nd line
- 3rd line - transcatheter angiography
- Non-anginal chest pain
- Patient has signs of IHD on 12 lead ECG = investigate as typical or atypical angina
- Patient has no signs of IHD on 12 lead ECG = explore other diagnoses, no further investigation for IHD at this point
- Look for precipiating and exacerbaitng factors (severe anaemia or cardiomyopathy)
What are the risks and triggers of prinzmetal or vasospastic angina?
- Smoking - not hypercholestolaemia or hypertension
- Cocaine
- Amphetamine
- Marijuana
- Low magnesium
How is prinzmetal angina (vasospastic angina) treated?
- Avoid triggers - soming, marijuana, cocaine, amphetamine
- Correct low magnesium
- PRN GTN
- Calcim channel blockers & Long acting nitrates
What drugs should be avoided in vasospastic anaemia or prinzmetal anaemia?
- Non-selective beta blockers
- Aspirin
- Triptans (used in migraines)
How is angina managed?
- Address the exacerbating factors - anaemia, tachycardia, thyrotoxicosis
- Secondary prevention of CVD:
- Exercise, Stop smoking, optimise diabetes and hypertension control
- Aspirin (if not contraindicated)
- Address hyperlipidaemia
- ACEi for hypertension
- PRN symptom relief - GTN spray or sublingual tabs (Glyceryl trinitrate) - repeat dose if it doesn’t work within 5 mins and if it still doesnt work, call an ambulance
- Anti-anginal medication
- Revascularisation
What are the side effects of GTN?
Headache
Low BP
What is the first line anti-anginal medication?
- Beta blocker and/or calcium channel blocker (do not combine the anti-dihydropyridine calcium antagonists with bbs)
- Atenolol or bisoprolol
- Amlodopine (dihydropyridine) or Diltiazem (anti-dihydropyrimidine)
Other than the first line anti-anginals, what are the other anti-anginal medications?
- Long acting Nitrates
- Isosorbide mononitrate or GTN patches
- Ivabradine
- Reduces HR without affect BP that much
- Patients must e in sinus rhythm to use it
- Ranolazine
- inhibits late sodium current
- Nicorandil - a K channel activator
How does ivabradine work?
- Ivabradine acts by reducing the heart rate via specific inhibition of the pacemaker current, a mechanism different from that of beta blockers and calcium channel blockers, two commonly prescribed antianginal drugs.
- Ivabradine is a cardiotonicagent.
