CVS: angina Flashcards
What are typical angina symptoms?
Chest pain with ALL 3 of:
* Precipitated by physical exertion/emotion (also can be due to cold weather, or after a large meal)
* Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
* Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
Not usually sharp or stabbing.
Not usually eased with antacids or simple analgesia.
What are atypical angina symptoms?
Chest pain with 2 of:
* Precipitated by physical exertion/emotion.
* Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
* Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
There may be atypical symptoms e.g. GI discomfort, and/or breathlessness, and/or nausea.
In secondary care, which investigation is used to diagnose stable angina?
computerised tomography-coronary angiography (CT-CA)
What are first line treatment for the relief of stable angina symptoms?
Sublingual GTN and beta blockers (or CCB if Bblocker contraindicated)
How should the diagnosis of stable angina be confirmed?
- if they have typical or atypical angina pain - refer to specialist chest pain service for further investigation.
- 12-Lead ECG asap - An abnormal ECG increases the likelihood of CAD but a normal ECG does not exclude it
ECG changes that may indicate ischaemia or previous myocardial infarction include:
- pathological Q waved
- LBBB
- ST and T wave abnormalities
What investigations should be done whilst they are awaiting diagnostic testing?
- FBC
- U&E
- Lipid profile.
- Fasting blood glucose or HbA1c.
- Thyroid function.
- ECG.
What advice and medication should be given whilst a/w diagnostic testing?
- s/l GTN spray
- IF they get chest pain:
- Stop what they are doing and rest.
- Use the GTN spray
- Take a second dose after 5 minutes if the pain has not eased.
- Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.
Consider starting aspirin 75mg OD until diagnosis confirmed (if typical angina symptoms)
What drug treatment is recommended for prinzmetal (vasospastic) angina?
a dihydropyridine CCB - e.g amlodipine
B-blockers can worsen the coronary spasm
If both B-blockers and CCBs are contraindicated or not tolerated, what should be given?
Monotherapy with one of the below drugs:
* A long-acting nitrate (such as isosorbide mononitrate).
* Nicorandil.
* Ivabradine.
* Ranolazine.
Review response 2-4 weeks after changing drug treatment.
What drug treatment should be started for 2ry prevention?
- offer antiplatelet- aspirin 75mg OD, unless previous stroke or PAD (will already be on clopidogrel and should continue with this)
- offer a statin
- offer anti-hypertensive treatment
- consider ACEI if stable andgina with diabetes.
what are the DVLA rules for angina?
- group 1: must stop driving if symptoms occur at rest, on emotion, or whilst driving. Can restart driving once symptoms controlled. Do not need to notify DVLA.
- Group 2: must not drive, must notify DVLA. Re-licensing can occur if free from angina for >6 weeks, they meet stress tests.
What is the advice for flying with angina?
- Chest pain on considerable exertion with no recent change in symptoms or medication — no restriction on air travel.
- Chest pain on minimal exertion with no recent change of symptoms or medication — consider airport assistance and possible in-flight oxygen.
- Chest pain at rest or a change in symptoms and/or medication — defer travel until stable, or travel with a medical escort and ensure in-flight oxygen is available.
Which medication can be added for a patient on monotherapy with uncontrolled symptoms?
- ensure taking maximum licensed/ highest tolerated dose.
- switch to or add a dihydropyridine CCB (e.g amlodipine, MR nifedipine, MR felodipine)
- If on dihydropyridine CCB - switch to or add a B-blocker.
- if CCB/B-blocker addition contraindicated/not tolerated - add a nitrate, nicorandil (postassium channel activator), ivabradine (HR >70), ranolazine (specialist advice for ivabradine/ranolazine)
What should be done for a patient on dual therapy with uncontrolled symptoms?
- ensure taking maximum licensed/ highest tolerated dose of each drug.
- refer to cardiology if on max doses of both drugs (for Ax for revascularization). Consider a 3rd anti-anginal whilst a/w Ax.
