Cardio - Angina

Question 1

suggest possible risk factors for angina

Answer 1

1. FHx
2. smoking
3. diabetes mellitus and metabolic syndrome
4. HTN
5. hyperlipidaemia
6. obesity and lack of exercise

Question 2

describe the 3 typical features of stable angina

Answer 2

1. constricting discomfort in front of chest, neck, shoulders, jaw or arm
2. precipitated by physical exertion (or emotional stress)
3. relieved by rest of GTN within about 5 mins

Question 3

how is unstable angina different to stable angina?

Answer 3

• new onset or abrupt deterioration of prev. stable angina
• often occuring at rest, lasts longer and not relieved by sublingual nitrates
• usually requires immediate admission or referral to hospital

Question 4

how would you investigate pts with suspected angina?

Answer 4

Depends on likelihood of angina based on clinical history and presentation:

• > 90%: arrange blood tests for conditions which exacerbate angina and treat as stable angina
• <90% but still high: invasive coronary angiography
• lower suspicion: non-invasive functional imaging. e.g. myocardial perfusion scintigraphy, stress echo, CT calcium scoring…

Bloods include: FBC (?anaemia), UandE (assess renal function), fasting blood glucose (?DM), fasting lipid profile (?hypercholesterolaemia), TFTs (?thyrotoxicosis or hypothyroidism), troponin T and I (if suggestion of permanent myocardial damage), baseline LFTs (before starting statins)

May also do ECG (but does not exclude Dx if normal) and echo (to assess cardiac function).

Question 5

How would you manage a pt with stable angina?

Answer 5

Conservative Mx: pt education, lifestyle advice, cardiovascular risk assessment and Mx

Pharmacology:

1. sublingual GTN - for symptom relief and prevention
2. B-blocker (e.g. atenolol) or CCB - 1st line regular Tx for symptom reduction
3. If above are contraindicated or not tolerated, consider monotherapy with 1 of the following: isosorbide mononitrate (long-acting nitrate), nicorandil, ivabradine or ranolazine
4. secondary prevention:
   
   • low-dose aspirin (75 mg daily) or clopidogrel if stroke or PAD
   • statin, e.g. atorvastatin
   • consider ACEi if also have DM, HTN, asymptomatic LV dysfunction, CKD or prev. MI

Question 6

suggest possible complications of angina

Answer 6

• MI
• stroke
• sudden cardiac death
• anxiety, depression, reduced QoL