Coronary Artery Disease

Question 1

What is coronary artery disease?

Answer 1

Plaque buildup in the coronary arteries which leads to narrowing. Initially this is asymptomatic but then causes stable angina and then can progress too unstable.

Question 2

What are the risk factors for coronary artery disease?

Answer 2

• Older age,
• Male sex,
• Smoking
• Obesity,
• History of CV disease,
• Hypertension
• hypercholesterolaemia

Question 3

What are the features of stable angina?

Answer 3

Defined by following 3 features:
1. Constrictive/heavy discomfort to chest which may radiate to jaw/neck/arm. May have associated symptoms
2. Brought on by exertion.
3. Alleviated by rest (<5mins) or GTN spray

Question 4

Explain the classification of stable angina

Answer 4

Class I - No angina with normal physical activity. Strenuous activity may cause symptoms.
Class II - Angina may cause slight limitation of normal activity.
Class III - Angina causes marked limitation of normal activity
Class IV - Angina occurs with any physical activity and may occur at rest (unstable angina)

Question 5

What are the differential diagnosis of stable angina?

Answer 5

• ACS,
• GORD,
• Costochondritis (pain can be reproduced when pressing on chest wall.
• Pleuritc chest pain (Pneumonia or PE)

Question 6

What are the investigations for stable angina?

Answer 6

In primary care - ECG, bloods (FBC, TFTs, troponin)
1st line investigation - CT Coronary angiogram.
2nd line (if CT CA is inconclusive) - Stress echo, myocardial perfusion SPECT or cardiac MRI

Question 7

What is the conservative management for stable angina?

Answer 7

• Smoking cessation,
• Sugar control,
• Hypertension management
• Hyperlipidaemia management,
• Wight loss,
• Reduce alcohol intake

Question 8

what is the medical management of stable angina?

Answer 8

• All patients should get Aspirin 75mg and Statin 80mg
• GTN
• Anti-anginal meds

Question 9

What are the 1st, 2nd and 3rd line anti-angina meds?

Answer 9

1st line - Beta blocker (bisoprolol) OR CCB (verapamil or diltiazem) but do not combine due to risk of heart block.
2nd line - Beta blocker AND dihydropyridine CCB (amlodipine or nifedipine)
3rd line - BB AND CCB AND long acting nitrite (at think point must consider revascularisation)

Question 10

What are the options for revascularisation?

Answer 10

Coronary artery bypass graft or percutaneous coronary intervention. Consider when symptoms not controlled by optimal medication or if there is 3 vessel disease/ significant left mainstem.

Question 11

What are the side effects of nitrites?

Answer 11

• Headaches,
• Flushing,
• Dizziness,
• Tolerance,

Question 12

What are the five principles for the management of stable angina?

Answer 12

RAMPS
R - referral to cardiology,
A - Advice them about diagnosis, management and when to call an ambulance,
M - Medical treatment
P - Procedural or surgical intervention
S - Secondary prevention