FN: Angina

Question 1

Pathophysiology

Answer 1

Atherosclerosis → Myocardial ischaemia

Question 2

Aetiology

Answer 2

Mostly atheroma
Anaemia
AS
Tachyarrhythmias
Arteritis

Question 3

Modifiable risk factors

Answer 3

• HTN
• DM
• Smoking
• Increased cholesterol
• Obesity

Question 4

Non-modifiable risk factors

Answer 4

• Age
• Male
• FH (MI <55yrs)
• Genetic: e.g. hyperlipidaemia

Question 5

Symptoms:

Answer 5

• Central chest tightness or heaviness
• Brought on by exertion, relieved by rest
• May radiate to one/both arms, neck, jaw or teeth
• Other ppts: emotion, cold weather, heavy meals

Question 6

Stable

Answer 6

Induced by effort

Question 7

Unstable

Answer 7

Induced by lying down

Question 8

Decubitus

Answer 8

Induced by lying down

Question 9

Prinzmetal’s/variant

Answer 9

Occurs during rest due to:
• Due to coronary spasm
• ST elevation during attack: resolves as pain subsides

Question 10

Treatment

Answer 10

Calcium channel blocker

Long acting nitrate

Question 11

Syndrome X:

Answer 11

Angina pain + ST elevation on exercise test but no evidence of coronary atherosclerosis.
→Probably represents small vessel disease

Question 12

Differential:

Answer 12

1. AS
2. Aortic aneurysm
3. GI: GORD, spasm
4. Musculoskeletal

Question 13

Investigations:

Answer 13

1. Bloods: FBC, U+E, lipids, glucose, ESR, TFTs
2. ECG: usually norml
   a. May show ST deression, flat/inverted T waves, past MI
   b. Consider exercise ECG
3. Stress echo
4. Perfusion scan
5. CT coronary Ca2_ score
6. Angiography (gold standard)

Question 14

Management medical 2 routes

Answer 14

Prevent cardiovascula events

Antianginals

Question 15

Prevent cardiovascular events

Answer 15

• Aspirin 75mg OD
• ACEi (esp. if angina + DM)
• Statins: simvastatin 40mg
• Anti-hypertensives

Question 16

Antianginals

Answer 16

• GTN (spray or SL) + either
→ 1st beta-blocker (e.g. atenolol 50-100mg OD)
→ 2nd: CCB (e.g. verapamil 80mg TDS)

• If either Beta-blocker of CCB doesn’t control symptoms try the other option
• Can try Beta-blocker + dihydropyridine CCB
e.g. amlodipine MR 10mg/24h

• If symptoms still not controlled
⇒ ISMN 20-40mg BD (8h washout @ PM) slow release nitrate (Imdur 60mg OD)
⇒ Ivabradine (esp.if cant take Beta-blocker)
⇒ Nicorandil 10-30mg BD
⇒ Ranolazine

Question 17

Surgical: CABG indications

Answer 17

⇒ L main stem disease
⇒ Triple vessel disease
⇒ Refractory angina
⇒ Unsuccessful angioplasty

Question 18

CABG complications

Answer 18

⇒	MI
⇒	Stroke
⇒	Pericardial tamponade or haemothorax
⇒	Postperfusion syn.
⇒	Post-op AF
⇒	Nonunion of ternum
⇒	Graft stenosis

Question 19

PCI

Answer 19

⇒ Poor response to medical Rx

⇒ Refractory angina but not suitable for CABG

Question 20

PCI complications

Answer 20

⇒ Re-stenosis (20-30% @6mo)

⇒ Emergency CABG (<0.5%)

Question 21

Clopidogrel reduces

Answer 21

Re-stenosis
⇒ Bare metal stent:1mo
⇒ Drug-eluting (e,g, sirolimus) stent:1yr