Angina Pectroris

Question 1

What is angina?

Answer 1

Angina is symptomatic reversible myocardial ischaemia. Angina can be either stable or unstable. Stable angina is most commonly caused by narrowing of the coronary arteries by atheromatous plaque formation, reducing blood supply to the heart muscle. In Unstable angina (Or an MI), these plaques rupture, causing thrombosis and platelet aggregation, which causes further acute obstruction of the vessel.
The pain in stable angina is felt during exercise - increased O2 demands of the heart and the shortened diastolic period (When the coronary arteries receive blood) causes ischaemia

Question 2

What are the causes of angina?

Answer 2

Most common – Atheroma

Others - Coronary artery spasm, Tachycardia, Vasculitis, Hypertrophic cardiomyopathy

Question 3

What will you ask about/find in history of angina?

Answer 3

Symptoms:
Chest Pain:
S - Central
Q - Crushing
I - Severe
T – Lasts a few minutes
A – Exercise, stress, cold
R – Rest or GTN spray (Within 5 minutes)
Systemic Symptoms - Dyspnoea, Nausea, Sweating, Fainting

Risk Factors:
Cardiovascular Risk Factors

Specific questions to ask in a history taking:
Is this typical angina - Typical angina has all 3 of central chest pain, brought on by exercise, relieved by rest/GTN (within 5 minutes)? Atypical angina has <3 of these
Differentiate Stable or Unstable Angina – Is the pain worse than normal or not being relieved by rest
Ask about known anaemia, thyroid problems or pregnancy that can increase the requirement of the heart and precipitate anaemia

Differentials:
MI - Pain is worse than stable angina, not relived by GTN/Rest, and there may be more systemic symptoms
GORD - Provoked by lying flat and eating/Improved with antacids, history of reflux
Biliary Colic – Pain is colicky in nature, more localised to the RUQ and patient may have risk factors of Gallstones. Worsened by fatty foods
Costochondritis – Point tenderness, commonly on the left costochondral margin
MSK Pain
Pancreatitis – No jaundice, systemic illness or radiation top the back
Pericarditis/Endocarditis – Pain not defendant on position and pain not pleuritic

Question 4

What will you look for/find in an examination of angina?

Answer 4

There are no signs specific for angina however examination is to assess for risk factors

End of the bed:
Obesity
Hands/Arms:
Tar Staining
Tendon Xanthoma indicating hyperlipidaemia
Poor peripheral pulses indicating Peripheral Vascular Disease
Hypertension
Face:
Xanthoma/Xanthalasma indicating hyperlipidaemia
Chest:
Assess for any underlying heart disease
Legs:
Poor peripheral pulses indicating Peripheral Vascular Disease

Question 5

What investigations will you order in suspected angina?

Answer 5

Bedside Tests:
Assess BMI
ECG – To look for any ST changes or pathological Q waves. Also as a baseline for further ECG’s
Capillary Glucose- To assess cardiovascular risk

Bloods:
FBC – Looking for precipitating anaemia or to rule out infective causes e.g. Pericarditis as the cause of the chest pain
U&E - Contrast will be used in coronary angiogram
LFT’s - Patient will be started on a statin
TFT - Looking for precipitating thyrotoxicosis
Troponin - To rule out an MI/Unstable angina
Lipids - To assess cardiovascular risk

Imaging:
CXR - Rule out differentials e.g. Pneumothorax, look for any underlying heart disease

Special Tests:
Cardiac Stress testing (1st line investigation)- Exercise ECG to assess severity of stenosis and exercise tolerance
CT angiography (2nd Line investigation) - CT with contrast used for diagnosis. Can jump straight to this if very certain of diagnosis
Echo - If Hypertrophic cardiomyopathy/Aortic Stenosis suggested

Question 6

What is the treatment of angina?

Answer 6

Lifestyle:
Educate on the features of a heart attack and when to come in e.g. GTN spray not relieving pain
Reduce Cardiovascular risk factors

Medical:
GTN spray to be used PRN – Up to 2 doses 5 mins apart
Beta Blocker or Calcium Channel Blocker as an anti-anginal therapy (2nd Line - Use the other instead, 3rd Line – Use both, 4th Line - Long acting nitrate (e.g. Isosorbide Mononitrate), Ivabradine (Funny current channel drug), Nicorandil (K+ Channel Activator), Ranolazine (Na channel blocker) or Ivabradine
Reducing Cardiovascular risk – Aspirin, Optimise Hypertension control, Optimise Diabetes control, Optimise Cholesterol control
Treat precipitating factors – Anaemia, Hyperthyroidism

Surgical:
PCI - If not controlled by medical treatment