Stable Angina

Question 1

Pathophysiology of angina

Answer 1

Symptoms associated with angina (e.g. constricting chest pain _ is due narrowing of the coronary blood vessels.

Narrowing of the coronary blood vessels leads to a ischaemia of distal myocardial structures, especially during times of high demand e.g. exercise.

Question 2

What are the two types of angina?

Answer 2

Stable Angina
- Symptoms improve with rest or with a GTN spray

Unstable Angina
- Symptoms appear randomly even at rest and do not improve with a GTN spray.

Question 3

What are the symptoms of angina?

Answer 3

• Constricting chest pain

- Radiation of pain to the jaw/arms

Question 4

What investigations are carried when suspecting a patient has angina?

Answer 4

Gold Standard Investigation is to do a CT coronary angiography, which uses contrast to see which coronary vessels are stenosed and is the cause of the symptoms.

Other baseline investigations to carry out include:
1) Cardiorespiratory examination to check for
> abnormal heart sounds
> signs of heart failure e.g. oedema of the legs, crackles on the chest
> weight and waist circumference (BMI) to check if the patient has any risk factors of cardiovascular disease e.g. obesity.

2) ECG (to detect any abnormality)
3) FBCs to check for anaemia
4) U&Es –> when starting ACEinhibiotors and other medications
5) LFTs –> useful prior to starting statins
6) Lipid profile to check their cholesterol levels –> to see if they are at high risk of developing atherosclerosis
7) Thyroid functions tests (to check for hypo/hyperthyroidism)
8) Hb1Ac and fasting glucose (for diabetes).

Question 5

How do you manage patients with angina?

Answer 5

There are 4 principles to managing patients with angina (RAMP).

1) Refer the patient to cardiology –> urgently if the patient has unstable angina.
2) Advise the patient on their diagnosis, and the management of the condition and when to call an ambulance during emergencies.
3) Medical treatment
4) Procedural or surgical interventions

Medical Management

• There are 3 main aims for medical management
  1) to provide symptomatic relief at the time of the event –> this is mediated by advising the patient to use their GTN spray. They should be told to take the GTN and then repeat after 5 minutes. If the patient experiences 5 minutes after the repeated dose, then call an ambulance.

2) to provide long-term symptomatic relief which involves the use of heart medications.
- beta blockers e.g. bisorporol 5mg OD
- calcium channel blockers e.g. amlodipine 5mg OD
These medications can be given individually or as a combination if the patient still experiences symptoms when on one medication.

Other heart medications can also be considered as well for example:

1) Long acting nitrates (e.g. isosorbide mononitrate)
2) Ivabradine
3) Nicorandil
4) Ranolazine

Although these medications are not given first line.

3) Secondary prevention
which involves the 4As.
- Aspirin 75mg OD
- Atorvastatin 80mg OD
- Atenolol (or other beta blockers e.g. bisporolol –> although these patients are already on a beta blocker for symptomatic relief)
- ACE inhibitors e.g. ramipril which is titrated to the maximum tolerated dose.

Procedural/Surgical Interventions

• Percutaneous Coronary Intervention (PCI) with coronary angioplasty
  > This involves passing a catheter via the brachial/femoral artery and passing into the coronary vessels under x ray guidance. Once reaching the coronary vessels, injecting a contrast to show any areas of stenosis which are highlighted by the X ray scans. These areas of stenosis are treated with balloon dilation and insertion of a stent.
  > Percutaneous Coronary Intervention is only offered to patients who have proximal or extensive disease as seen on CT angiography.
• Coronary Artery Bypass Graft (CABG)
• Involves the use of a graft taken from the great saphenous vein) and sewing it to the affected coronary artery, to bypass the stenosis. In this surgery, the chest is opened along the sternum as evidenced by a midline sternotomy scar.

TOMTIP

• Look at the patient’s chest to check for a midline sternotomy scar and if they do have it, look at their calves to see if there is a scar to show evidence of saphenous harvesting.
• Look at the arms and thighs to check for any evidence of brachial artery or femoral artery access which would indicate prior percutaneous coronary intervention surgeries taking place.