Stable angina Flashcards
Stable angina: definition
Chest pain typical of angina is defined by the following 3 features.
- Constriction like pain in chest/neck/arm/jaw
- Brought on by physical activity
- Alleviated by rest or glyceryl trinitrate within minutes
2/3 features indicate atypical angina pain
Stable angina: initial investigations
- ECG
- Bloods
- FBC (check for anaemia, which can cause exertion and chest pain)
- TFTs to exclude hyperthyroidism
- lipid profile
- HbA1c
Stable angina: imaging
1st line –> CTCA (or functional imaging)
2nd line –> Myocardial perfusion SPECT
Stress ECHO
MRI for regional wall motion abnormalities
3rd line –> coronary angio
Stable angina: 1st line management
A. Alternative to usual pharmacological therapy
- Conservative - risk factor modification + 2ndary prevention medicine e.g. aspirin + statin
- GTN AND beta-blocker or rate-limiting calcium channel blocker
A. Long-acting nitrate e.g. Isosorbide Mononitrate
Ivabradine
Nicorandil
Ranolazine
Side effects of GTN
- What to do if chest pain does not subside?
- When to be worried
headaches, flushing, dizziness
- Take another dose after 5min of 1st
- Chest pain continues after 2 doses of GTN
Stable angina: 2nd line management
GTN + long-acting DHP CCB + ß blocker
Stable angina: 3rd line management
A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs.
Coronary angiography should be arranged unless contraindicated as PCI may be required
ACE-inhibitors for patients with diabetes and hypertension should be considered
Indications for revascularization in stable angina
- Their symptoms are not satisfactorily controlled on optimal medical treatment AND
- complex 3 vessel disease or
- significant left main stem stenosis
PCI more cost-effective than CABG
BUT
CABG has a mortality advantage over patients who:
1. are over 65 years old
2. have diabetes
3. anatomically complex 3 vessel disease (with or without left main stem stenosis)
