IHD – Stable Angina

Question 1

Define stable angina

Answer 1

Chest pain which is provoked by exertion, but alleviated with rest

Question 2

Describe the pathophysiology for stable angina

Answer 2

• Angina occurs due to a mismatch in myocardial perfusion and myocardial demand
  – basically oxygen supply cannot meet demand -> myocardial ischaemia

Question 3

What is the most common mechanism for stable angina?

Answer 3

atherosclerotic plaque formation in the coronary arteries which causes stable narrowing of the lumen, thus coronary perfusion decreases

Question 4

What is a less common cause of stable angina?

Answer 4

coronary vasospasm (AKA Prinzmetal’s angina)

Question 5

Around what % of stenosis of an artery will result in stable angina?

Answer 5

~70%

Question 6

What are the symptoms of stable angina?

Answer 6

• Chest pain(pressure-like, heavy, squeezing) which is provoked by exertion, but is alleviated with rest, lasts less than 20 minutes and radiates to left arm and jaw
• May be accompanied by breathlessness, fatigue

Question 7

What are investigations for stable angina?

Answer 7

• ECG – (main)
• CT coronary angiography – primary diagnostic investigation
• CXR – rule out non-cardiac causes
• Myocardial perfusion scan
• Echocardiogram
• Angiogram (invasive)

Question 8

What does stable angina show on ECG?

Answer 8

• exercise/resting
• During exercise may present w:
  ST depression due to subendocardial ischaemia, PVC, bundle branch abnormalities

Question 9

What are the modifiable risk factors of stable angina?

Answer 9

Hypertension
Hyperglycaemia (DM)
Smoking
Alcohol
Hypercholesterolaemia
Obesity/inactivity
Stress

Question 10

What are the non-modifiable risk factors of stable angina?

Answer 10

Age
Sex (men and post-menopausal women)
Genetic/Family History

Question 11

What is the immediate relief treatment for stable angina?

Answer 11

• Typically GTN spray
• Sublingual spray (avoids 1st pass)
• Do on onset of symptoms
• Wait 5 mins, 2nd spray if persists
• Wait 5 mins, 3rd spray if persists
• If still pain after 5 mins, call an ambulance

Question 12

What can be used if GTN is not an option for immediate relief of stable angina?

Answer 12

• longer-acting nitrates
• isosorbide mono/dinitrate

Question 13

What is the long-term treatment for stable angina?

Answer 13

• Beta-blocker and/or Calcium Channel blocker (may depend on tolerance, contraindications etc)
• otherwise may consider Ivabradine, Nicorandil etc

Question 14

What is the secondary prevention of stable angina?

Answer 14

• 3A’s

Atorvastatin 80mg
Aspirin 75mg
ACEi (if DM, HTN, CKD, HF present)

Question 15

If stable angina is persistent what can you consider for treatment?

Answer 15

• PCI – single or double vessel disease
• CABG – triple vessel or left main stem disease