Stable Angina

Question 1

Angina?

When do symptoms arise?

Answer 1

Narrowing of the coronary arteries = reduces blood flow to the myocardium

Symptoms arise when during times of high demand (e.g. exercise) when there is insufficient supply of blood to meet demand

Question 2

What are the symptoms of angina?

Answer 2

constricting chest pain with or without radiation to jaw or arms

Question 3

Stable vs unable angina?

Answer 3

Angina is “stable” when symptoms are always relieved by rest or glyceryl trinitrate (GTN)

It is “unstable” when the symptoms come on randomly whilst at rest, and this is considered as an Acute Coronary Syndrome

Question 4

Investigations for angina?

Answer 4

GOLD STANDARD = CT coronary angiography (injecting contrast and taking CT images of coronary arteries)

In addition, all patients should have following investigations:-

• physical exam (heart sounds, signs of heart failure, BMI)
• ECG
• FBC (check for anaemia)
• U&Es (prior to ACEi and other meds)
• LFTs (prior to statins)
• Lipid profile
• Thyroid function tests (check for hypo/hyper thyroid)
• HbA1C and fasting glucose for diabetes

Question 5

Management of angina?

Answer 5

R – Refer to cardiology (urgently if unstable)
A – Advise them about the diagnosis, management and when to call an ambulance
M – Medical treatment
P – Procedural or surgical interventions

Question 6

Immediate symptomatic relief vs long term symptomatic relief for angina?

Answer 6

Immediate symptomatic relief

GTN spray - causes vasodilation and helps relieve symptoms
Take GTN then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance!

Long Term Symptomatic Relief is with either (or used in combination if symptoms are not controlled on one):

Beta blocker (e.g. bisoprolol 5mg once daily)
Calcium channel blocker (e.g. amlodipine 5mg once daily)

Other options (not first line):
Long acting nitrates (e.g. isosorbide mononitrate)
Ivabradine
Nicorandil
Ranolazine

Question 7

Secondary prevention angina?

Answer 7

Aspirin (i.e. 75mg once daily)
Atorvastatin 80mg once daily
ACE inhibitor
Already on a beta-blocker for symptomatic relief

Question 8

Surgical interventions for angina?

Answer 8

Percutaneous Coronary Intervention (PCI) with coronary angioplasty (dilating the blood vessel with a balloon and/or inserting a stent) is offered to patients with “proximal or extensive disease” on CT coronary angiography. This involves putting a catheter into the patient’s brachial or femoral artery, feeding it up to the coronary arteries under xray guidance and injecting contrast so that the coronary arteries and any areas of stenosis are highlighted on the xray images. This can then be treated with balloon dilatation followed by insertion of a stent.

Coronary Artery Bypass Graft (CABG) surgery may be offered to patients with severe stenosis. This involves opening the chest along the sternum (causing a midline sternotomy scar), taking a graft vein from the patient’s leg (usually the great saphenous vein) and sewing it on to the affected coronary artery to bypass the stenosis. The recovery is slower and the complication rate is higher than PCI.

Question 9

Examination coronary artery disease?

Answer 9

TOM TIP: When examining a patient that you think may have coronary artery disease, check for a midline sternotomy scar (previous CABG), scars around the brachial and femoral arteries (previous PCI) and along the inner calves (saphenous vein harvesting scar) to see what procedures they may have had done and to impress your examiners.