Myocardial ischemia -Stable angina

Question 1

outline what causes stable angina and describe some of its characteristics

Answer 1

1) results from atherosclerotic plaques in the coronary arteries that restrict blood flow and oxygen supply to the heart
2) occurs predictably with physical exertion or emotional stress, last for no more than 10 minutes (usually less) and is relieved within minutes of rest or with medication

Question 2

1) what medication is used to manage acute attacks of stable angina?
2) when should it be taken?

Answer 2

1) Sublingual GTN

2) Taken immediately before performing activities that are known to bring on an attack

Question 3

Outline the counselling advice given to patients regarding using their GTN spray for an attack and explain when should they call 999

Answer 3

if patient experience chest pain they should:

1) Stop what they are doing and rest.
2) Use GTN spray or tablets
3) Take a second dose after 5 minutes if the pain has not eased.
4) Call 999 if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying

Question 4

How should patients who experience attacks more than twice a week be managed?

Answer 4

Regular drug therapy which should be introduced in a step-wise manner according to response

Question 5

1) which two drugs are prescribed as first-line in the regular treatment of stable angina to reduce symptoms?
2) what should be done if monotherapy with the above agents, fail to control symptoms adequately?

Answer 5

1) Beta-blocker or a calcium-channel blocker
↳ If the person cannot tolerate one, consider switching to the other
2) A combination of a B-blocker and a Dihydropyridine CCB (e.g. amlodipine, felodipine, M/R nifedipine) should be used.
↳ (If EITHER a B-blocker or CCB is not tolerated consider addition of long acting nitrate, ivabradine, nicorandil or ranolazine)

Question 6

what should be done if both beta-blockers and CCBs are contraindicated or not tolerated in patients with stable angina?

Answer 6

Consider monotherapy with a long acting nitrate (such as isosorbide mononitrate), nicorandil, ivabradine or ranolazine

Question 7

when should response to treatment be assessed in stable angina?

Answer 7

Every 2-4 weeks after initiating treatment or changing drug therapy. Titrate the dose against symptoms up to the maximum licensed or tolerated dose.
↳ refer to specialist if a combination of two drugs fail to control symptoms

Question 8

under what circumstances should the addition of a third antianginal drug be considered?

Answer 8

If symptom control is not achieved with two drugs AND the patient is due to undergo a revascularisation procedure or a revascularisation procedure is considered inappropriate

Question 9

what side effects can nicorandil (potassium channel activator) cause?

Answer 9

serious skin, mucosal and eye ulceration; including GI ulceration, which might progress to perforation ect. Stop treatment if this occurs

Question 10

what patient and care advice should be given to people prescribed nicorandil?

Answer 10

warned not to drive or operate machinery until it is established that their performance is unimpaired

Question 11

how does ivabradine lower heart rate and when is it licensed to be used in stable angina?

Answer 11

1) Lowers heart rate by its action on the SA node
2) only licencsed in angina in those who are in normal sinus rhythm in combination with B-Blockers or when B-blockers are contra-indicated or not tolerated