Chronic Stable Angina

Question 1

What is stable angina and when does it occur?

Answer 1

Narrowing (stenosis) of an epicardial coronary artery due to atherosclerosis. Occurs during exercise = as a result of demand ischaemia and will present as crushing pain in the chest.

Question 2

What is the treatment for stable angina and what are the aims of the treatment?

Answer 2

Treatment = nitro vasodilator
Aims is to stop or minimise symptoms, improve quality of life by increasing tolerance to exercise and reduce risk of developing major cardiovascular event e.g. unstable angina or MI

Question 3

When should nitrate therapy (glyceryl trinitrate) be used and when should emergency services be called?

Answer 3

When get pain and before exercise/exertion. Can repeat dose after 5 mins but if pain still hasn’t gone after a further 5 mins - emergency services should be called.

Question 4

How else do we manage chronic stable angina?

Answer 4

Lifestyle management:

1. ) Diet - fruit, veg, oily fish, unsalted nuts, fibre
2. ) Smoking cessation
3. ) Not going over units of alcohol
4. ) Blood pressure management

Question 5

What is the MoA of the nitrates?

Answer 5

Cause dilation in the venous circulation = reduction in the preload (blood that returns to the heart) = tless stretching of heart = he heart doesn’t have to work as hard to pump all the blood out and there is a reduction in oxygen demand.

Question 6

What is the long-term management/ prophylaxis of stable angina?

Answer 6

In the long-term, patient should be on drug that reduces cardiac oxygen demand in order to minimise the frequency of attacks.
B-blockers or CCB’S

Question 7

What is the first step in the long-term management/ prophylaxis of stable angina?

Answer 7

1.) Beta blocker (reduce HR and contraction) or CCB (if cardio selective can reduce HR and contraction)
If have LV dysfunction chose B-blocker and avoid phenylalkaline CCBs

Question 8

What is the second step in the long-term management/ prophylaxis of stable angina?

Answer 8

2.) Beta blocker PLUS dihydropyridine CCB

Question 9

What is the third step in the long-term management/ prophylaxis of stable angina?

Answer 9

3.) add a long acting nitrate e.g. nicorandil

Question 10

when would revascularisation be considered?

Answer 10

For high risk patients who aren’t responding to treatment. An angiography is used to aid in decision making - camera to see the extent of damage

Question 11

What would happen in revascularisation?

Answer 11

1. ) If multiple vessels are affected: A CABP (coronary artery bypass graft) is used to re-route circulation = take a vein e.g. from the back of the leg and graft onto the heart.
2. ) If only one major vessel is affected - PCI = catheter is put up leg or arm and moved into a vessel. A balloon is the inflated to open the vessel and the stenosis is removed. A mesh is inserted to keep vessel open.

Question 12

What is secondary prevention/ post vascularisation treatment in stable angina?

Answer 12

1. ) Aspirin 75mg OD for life (taking into account the risk of bleeding)
2. ) ACE inhibitor if not already on one for HT
3. ) Statin even if cholesterol levels aren’t high