Cardiology - Stable Angina

Question 1

What causes angina?

Answer 1

Atherosclerosis affecting coronary arteries which narrows the lumen

This reduces blood flow to the myocardium, thus during exercise or high demand it leads to angina

Question 2

When is angina stable?

Answer 2

Symptoms only come on with exertion and always relieved by rest or glyceryl trinitrate

Question 3

When is angina unstable?

Answer 3

Symptoms appear randomly while at rest

Unstable angina is a type of acute coronary syndrome, requires immediate management

Question 4

What baseline investigations should be done for patients with angina?

Answer 4

Physical examination
ECG
FBC (anaemia)
U&Es (before ACEi)
LFTs (before statins)
Lipid profile
TFTs
HbA1C and fasting glucose

Question 5

What is cardiac stress testing?

Answer 5

Assessing patients heart function during exertion e.g.
Exercise (treadmill)
Medication (dobutamine)

ECG, echo, MRI or myocardial perfusion scan used during stress testing to assess function

Question 6

What is the gold standard for determining coronary artery disease?

Answer 6

Invasive coronary angiography

Catheter inserted into patients brachial or femoral artery to aorta and coronary arteries under x-ray

Contrast used to visualise coronary arteries and identify stenosis

Question 7

Where are patients with angina sent to when referred normally?

Answer 7

Rapid access chest pain clinic

Question 8

What are the aims of medical management of angina?

Answer 8

Immediate symptomatic relief
During episodes of angina

Long-term symptomatic relief

Secondary prevention

Question 9

What is used for immediate symptomatic relief of symptoms and what are patients advised?

Answer 9

Sublingual glyceryl trinitrate, causes vasodilation

Take GTN when symptoms start

Take second dose after 5 minutes if needed

Take third dose after 5 minutes if needed

Call an ambulance if symptoms remain after 5 minutes

Question 10

What are the main side effects of GTN?

Answer 10

Headaches and dizziness caused by vasodilation

Question 11

What is the first-line for long-term symptomatic relief?

Answer 11

Beta blocker (bisoprolol)
Calcium-channel blocker (diltiazem or verapamil, both avoided in HFrEF)

Question 12

What other options can be considered for long-term symptomatic relief?

Answer 12

Long-acting nitrates (isosorbide mononitrate)

Ivabradine

Nicorandil

Ranolazine

Question 13

What are the 4As of secondary prevention?

Answer 13

Aspirin 75mg
Atorvastatin 80mg
ACEi
Atenolol or other beta blocker

Question 14

What surgical interventions are offered to patients with severe disease?

Answer 14

Percutaneous coronary intervention (PCI)

Coronary artery bypass graft (CABG)

Question 15

What do PCI and CABG involve?

Answer 15

Percutaneous coronary intervention
Catheter inserted through patient’s brachial or femoral artery

Fed in under x-ray guidance to coronary arteries

Contrast used to identify stenotic areas, balloon is dilated to widen the lumen (angioplasty), stent is then inserted to keep it open

Coronary artery bypass graft
Surgery for severe stenosis

Midline sternotomy incision made

Graft vessel attached to affected coronary artery, bypassing stenotic area

Question 16

What vessels are used for coronary artery bypass grafts?

Answer 16

Saphenous vein
Internal thoracic artery
Radial artery

Question 17

Label these scars

Answer 17