Chapter 2 - Stable Angina Flashcards
What are the symptoms of stable angina?
Predictable chest pain
This may radiate to the neck, shoulders, jaw or arms
Precipitated by exercise or stress
Relieved by rest/GTN
What happens during a stable angina?
There is atherosclerotic plaques in the coronary arteries that restrict the flow of blood and oxygen to the heart
There is also an increase in oxygen demand within the heart due to exercise/stress
What are some complications of angina?
Unstable angina
MI
Stoke
What is Prinzmetal’s angina?
This is caused by narrowing of the proximal coronary artery due to spasm, causing pain at rest
How should acute angina attacks be managed?
With sublingual GTN (tablets or spray)
When chest pain is experienced:
Stop activity and rest
Take sublingual GTN
If pain persists after 5 mins, take another
If pain persists 5 mins after the second dose, call 999
When should long term anti-anginal therapy be considered?
When patients are experiencing more than 2 acute anginal attacks a week
What is first-line for long-term prevention of angina?
Beta blockers e.g. atenolol, bisoprolol
Or rate limiting CCB e.g. diltiazem, verapamil
What should be done if beta-blockers or CCBs alone fail to control anginal symptoms?
Use a beta-blocker and a dihydropyradine CCB e.g. amlodipine
What should be done if beta-blockers and/or CCBs don’t effectively control anginal symptoms?
Add either a: Long acting nitrate Nicorandil Ivabradine Ranolazine
When should a patients response to anginal treatments be monitored?
2-4 weeks after a change in drug therapy
Should patients with angina be considered for secondary prevention of CV events?
Yes - aspirin 75mg daily and a statin
And an ACEi should be considered especially if the patient has diabetes
What is the mechanism of action of nitrates?
Reduction in venous return (which reduced left ventricular work)
Coronary vasodilator
How long does the effect of GTN sublingual tablets/spray last?
20-30 mins
How long does the action of isosorbide dinitrate last?
Standard release - a few hours
Modified release - 12 hours
What are the contraindications of nitrates?
Hypotension
Hypovolaemia
Marked anaemia
Which formulation of nitrates carries the highest risk of tolerance and how is this risk reduced?
Transdermal patches
Leave off for 8-12 hours a day (usually this is overnight)
When should isosorbide mononutrate be taken?
Standard release, usually BD, take second dose 8 hours after the first to reduce the risk of tolerance
Modified release - usually OD
What are the side effects of nitrates?
Flushing
Headache
Postural hypotension
Arrhythmia
When should GTN tablets be discarded after opening?
8 weeks
Which GTN preparations are P meds?
Tablets
Spray
Patch
What is the MRHA advice regarding nicorandil?
Nicorandil can cause serious skin, mucosal, eye and GI ulceration
When can ivabradine be given in angina?
Patients who are in sinus rhythm
Patient who have a heart rate >70bpm (discontinue below 59bpm)
What does ivabradine interact with?
CYP3A4 inhibitors
Other drugs that also prolong the QT interval e.g. amiodarone
What are some side effects of ranolazine?
Weight loss
QT interval prolongation
AKI
Dehydration
What is the brand name of ranolazine?
Ranexa
What group of anti anginal drugs commonly causes peripheral oedema?
CCBs
Can beta blockers be used with verapamil or diltazem?
No
Risk of bradycardia and hypotension
When should ivabradine be discontinued in stable angina?
Heart rate falls below 50bpm
No effect after 3 months
What is the most cardioselective CCB?
Verapamil
Which cardio drug can cause gingival hyperplasia?
CCBs
Which CCB commonly causes constipation?
Verapamil
Should patients sit or stand when taking nitrates?
Sit - can cause dizziness
