ix and mx of suspected angina pectoris

Question 1

which patients with chest pain do you ix for angina pectoris

Answer 1

• if clinical assessment fails to identify any other reason for chest pain apart from angina/acute mi
• dont do in all pts presenting w/ chest pain

Question 2

first thing to do: how to evaluate clinical presentation + assess cardiac rfs: [HEART SCORE]

Answer 2

History

• highly suspicious- specific features dominate [SCORE 2]
• moderately susp - mix of specific + atypical features [SCORE 1]
• non-specific- no specific features [SCORE 0]

Ecg

• significant ST depression [in absence of BB/LVH/digoxin] - 2
• any other abnormality - 1
• normal- 0

Age

• >65yo
• 45-60yo
• <45yo

Rfs

• morethan/equal to 3RFs or known atherosclerosis
• 1 or 2 RFs
• 0 RFs

Troponin I

• >80yo
• 40-80yo
• <40yo

total of these scores stratifies pts into 3 risk groups

1. LOW- 0-3
2. MODERATE 4-6
3. HIGH ≥ 7

Question 3

specific features of CARDIAC CHEST PAIN

Answer 3

site: central/retrosternal
character: pressure, heaviness, squeezing, burning, indegestion-like
radiation: arms, neck, jaw

provoking factors: exercise, stress, cold, lying down

releiving factors: rest, GTN

assosiated symptoms: nausea, sweating, SOB

duration: >13min

Question 4

RFs

Answer 4

• DM
• smoking- recent [<80d] or current
• high xol
• fhx of cvd
• obesity

no RFs - score: 0

1 or 2 RFs- score 1

≥ 3RFs- score 2

also score if hx of:

• coronary revascularisation
• mi
• stroke
• PAD

Question 5

second thing to do after assessing cardiac RFs

Answer 5

do 12 lead ecg on arrival + before discharge

refer if further episodes of pain occur

Question 6

if st elevation present, what to do

Answer 6

see acute mi notes

Question 7

mx of Patients presenting with acute chest pain

Answer 7

Patients presenting with acute chest pain

Immediate management of suspected acute coronary syndrome (ACS)

• glyceryl trinitrate
• aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
• do not routinely give oxygen, only give if sats < 94%*
• perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS

Referral

• current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
• chest pain 12-72 hours ago: refer to hospital the same-day for assessment
• chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

Patients presenting with stable chest pain

NICE guidelines the risk of a patient having (CAD) is calculated based on their symptoms (whether they have typical angina, atypical angina or non-anginal chest pain), age, gender and risk factors.

NICE define anginal pain as the following:

1. constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
2. precipitated by physical exertion
3. relieved by rest or GTN in about 5 minutes

• patients with all 3 features have typical angina
• patients with 2 of the above features have atypical angina
• patients with 1 or none of the above features have non-anginal chest pain

If patients have typical anginal symptoms and a risk of CAD is greater than 90% then no further diagnostic testing is required.

It should be noted that all men over the age of 70 years who have typical anginal symptoms fall into this category.

Question 9

mx For patients with an estimated risk of 10-90%

Answer 9

For patients with an estimated risk of 10-90% the following investigations are recommended. Note the absence of the exercise tolerance test:

Answer 10

Medication

all patients should receive aspirin and a statin in the absence of any contraindication

sublingual glyceryl trinitrate to abort angina attacks

NICE recommend using either a beta-blocker or a calicum channel blocker first-line based on ‘comorbidities, contraindications and the person’s preference’

if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine).

💀💀💀Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)

if a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa

if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

Nitrate tolerance

many patients who take nitrates develop tolerance and experience reduced efficacy

the BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness

this effect is not seen in patients who take modified release isosorbide mononitrate

Ivabradine

a new class of anti-anginal drug which works by reducing the heart rate

acts on the If (‘funny’) ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity

adverse effects: visual effects, particular luminous phenomena, are common. Headache. Bradycardia, due to the mechanism of action, may also be seen

there is no evidence currently of superiority over existing treatments of stable angina

Question 11

Side-effects of common drugs: anti-anginals

Answer 11