Stable Angina

Question 1

Epidemiology

Answer 1

Men
+ 45
Women + 55

Question 2

Risk Factors

Answer 2

Smoking
Sedentary lifestyle
Obesity
Hypertension
Diabetes Mellitus
Family History
Genetics
Age
Hyperaldosteronism

Question 3

Pathophysiology

Answer 3

Atherogenesis - endothelial injury induces cells to site via chemokines (IL1, 1L6, IFN-Y) ->
FATTY STREAK - appears in intimal wall (less than 10 y/o V.EARLY) - T cells, + lipid laden macrophages (FOAM CELLS)
Intermediate Lesions - foam cells (bigger, taken up more lipid), t cells, vascular smooth muscle cells
platelets also aggregate + adhere to the site, inside vessel lumen
Fibrous plaques (advanced) - large lesions (foam cells, t cells, smooth muscle, fibroblasts, lipid increase with a necrotic core) develop fibrous cap over top of lesion
Stable angina = fibrous cap is strong + less rupture prone

Question 4

Aetiology

Answer 4

Atheroma/Stenosis of coronary arteries thereby impairing blood flow = MOST COMMON CAUSE
Valvular disease (Aortic Stenosis)
Hypertrophic Cardiomyopathy
Anaemia

Question 5

Anginal Pain Triad

Answer 5

1. Central crushing chest pain radiating to neck/jaw
2. Brought on with exertion
3. Relieved with 5 minutes rest and GTN spray
   (3/3 - stable, 2/3 - atypical 1/3 - non-typical)

Question 6

Signs

Answer 6

LeVine’s sign (clenched fist over chest)
Dyspnoea
Diaphoresis (sweating)
Exacerbated by cold weather, heavy meals, emotion)
Relieved by GTN spray

Question 7

Symptoms

Answer 7

central crushing pain radiating to jaw, neck and shoulder

Question 8

Crescendo Angina

Answer 8

When attacks increase in frequency and/or severity as is correlated with high risk of ACS

Question 9

Diagnosis

Answer 9

FIRST LINE = ECG - usually normal but may show ST depression + T wave inversion
GOLD STANDARD = CT angiography - stenosed atherosclerotic arteries
Bloods - FBC, Cardiac enzymes, lipids
Chest X-ray
Echo

Question 10

Treatment

Answer 10

FIRST LINE = Lifestyle education
- Weight loss
- More exercise
- Quit smoking
Symptomatic - GTN sublingual spray
(Common side effect = headaches)
1. Beta blockers (CI in asthma instead use CCB = Amlodipine)
2. CCB (Non-Rate Limiting as can cause excessive bradycardia = amlodipine, NOT verapamil, diltiazem) + BB
3. CCB + BB + another antianginal (e.g., Ivabradine or long-acting nitrate e.g isosorbide mononitrate - not GTN spray)
Drugs to consider = ACE-I, Aspirin, Statin, HTN treatment
If unsuccessful = PCI (balloon stent) - less invasive, risk of stenosis or CABG (bypass graft) - better prognosis, more invasive