Coronary Vessels: Stable Angina

Question 1

Presentation of stable angina

-what would be considered angina, atypical angina and not angina

Answer 1

1. Constricting sensation at front of chest => neck, jaw, arms, shoulder for 15mins
2. Worse on exercise/emotional stress
3. Relieved by rest/GTN in less than 5mins

3 - angina
2 - atypical
0 - not angina

Question 2

Differentiating between
-typical angina pain
-atypical angina pain
-non angina pain
How would you manage these 3 groups?

Answer 2

ECG for all presenting to rapid access chest pain clinic
STEMI => PCI!
NSTEMI => CONSIDER PCI

Non angina pain with no ECG changes => consider alt

Typical (3)/atypical (2)/not angina with ECG changes => CTCA

Question 3

Questions to differentiate between typical and atypical angina pain

Answer 3

If you do the same exercise on 10 different occasions, how often do you get the pain
T - 10 (v reproducible pain)
A - U10

If you have 10 pains in a row, how many happen when you are sitting quietly
T - 0/1
A - 1+

How long does the pain usually last
T - U5mins
A - 5+ mins

Question 4

Clinical history and physical examination

-Assessing pretest probability of disease

Answer 4

Past

• AMI
• CABG/PCI
• CV risk factors
• Past tests on heart

Physical exam

• signs of CVD
• any non coronary causes of chest pain?
• is it GI/MSK pain?

Question 5

Initial management of stable angina

• diagnostic investigation
• confirmation

Answer 5

Blood tests - identify conditions that exacerbate angina (anemia)
ECG - signs of ischemia or past MI

1st line - CTCA
2nd line if CTCA non diagnostic/unknown functional significance - non invasive functional testing

CTCA - significant CHD found
NIFT - reversible ischemia found

Question 6

Management of angina

• acute attacks
• ongoing
• 2ndary prevention

Answer 6

Acute - GTN during attack/before physical exertion

1st line - Bb/CCB
2nd line - monotherapy long acting nitrate/ivabradine/nicorandil/ranolazine

Statin + HTN management
-if not managed well medically => consider PCI/CABG