stable angina Flashcards
what is stable angina
- predictable chest pain/pressure, often precipitated by physical exertion or emotional stress which causes increase in myocardial oxygen demand
- relieved within a few mins of resting
stable angina usually results from
atherosclerotic plaques in coronary arteries which restrict blood flow and oxygen supply to heart
describe the pain in stable angina
- typically occurs in front of chest
- can spread to neck, jaw, left arm, shoulder
complications of stable angina
- unstable angina
- stroke
- MI
- sudden cardiac death
Prinzmetals or vasospastic angina
- rare form of angina, not caused by atherosclerosis
- caused by narrowing or occlusion of proximal coronary arteries due to spasm
- pain is experienced at REST
how to treat acute attacks of stable angina
- sublingual GTN
How to use sublingual GTN for the treatment of angina
- one tab/1-2 sprays under tongue and close mouth
- dose may be repeated at 5 min intervals if needed
- seek urgent medical care if symptoms not resolved 5 mins after second dose, or earlier if pt unwell/pain is intensifying
- max 3 doses
how to use sublingual GTN for angina prophylaxis
1 tablet/400–800 micrograms to be administered under the tongue and then close mouth prior to activity likely to cause angina.
long term prevention of chest pain in pt with angina
- BB (or RL-CCB instead)
- dual therapy of BB + any CCB licensed (if they are taking BB, prescribed DHPN CCB e.g. amlod, felod, MR nifed)
avoid verap + BB same time - significant interaction, increased risk adverse CV events
- if either BB or CCB cannot be given, add vasodilator as dual therapy (LA nitrate, ivabradine, nicorandil, ranolazine)
- if both BB and CCB can’t be given, vasodilator mono therapy (LA nitrate, ivabradine, nicorandil, ranolazine)
4 BB that are licensed for angina long term treatment - PBAM
propranolol
bisoprolol
atenolol
metoprolol
Can you give BB in Prinzemtal’s angina
no it is contraindicated! give RL-CCB instead e.g. verapamil or diltiazem
DHPRDN-CCB e.g. amlodipine may also be effective
What is used for treatment of Prinzmetals angina
NOT BB they are contraindicated!!
RL CCB or DHPDN CCB e.g. amlodipine
MOA nitrates
- potent coronary vasodilators
- reduce venous return to heart, thus reduce LV work (blood pumped out by heart) = less CO = less strain on heart
Examples of vasodilators that can be used in angina long term prevention therapy (e..g if a BB or CCB not suitable)
Long acting nitrate (e.g. isosorbide mono/dinitrate), ivabradine, nicorandil, ranolozine
Cautions nitrates - long acting or transdermal preps
- many pt taking these quickly develop tolerance
- constant levels of nitrates in blood = body becomes desensitised
- progressively higher dose needed for same therapeutic effect
- to overcome, choose dose timings that leave blood nitrate free or with very low levels for 4-12 hours everyday
- e.g. remove patches for 8-12h (e.g. overnight)
- when a LA nitrate taken BD, take 2nd dose after 8 h instead of 12 hours so it doesn’t cover a 24h period
- MR isosorbide mononitrate to be taken OD
SE of nitrates
- vasodilators: flushing, throbbing headache, postal hypotension
interactions of nitrates
- SE if hypotension, so taking two or more drugs = increased risk of hypotension
- e.g. antihypertensives, alpha blockers, BBs, antidepressants, antipsychotics, diuretics, SGLT2i (e.g. canag)
- e.g. SEVERE, avoid phosphodiester-type 5 inhibitors (e.g. sildenafil)
when to assess response to treatment
- every 2-4 weeks after initiation or change of drug therapy
- titrate drug doses to max tolerated effective dose
when to refer to specialist
- combination of two drugs at max therapeutic doses fail to control angina symptoms
does having angina put you at increased risk of CV events
yes
secondary prevention of CV events
- lifestyle factors e.g. smoking cessation, weight management, increase physical activity
- all pt with arable angina due to atherosclerotic disease should be given long term treatment with lose dose aspirin + statin
consider ACEi also esp if pt has diabetes
how long does the effects of sublingual GTN last
provides rapid symptomatic relief, but effect only lasts 20-30 mins
expiry of sublingual GTN tablets
8 weeks after opening!!
MHRA nicorandil
ulcers of mouth, mucosa, GI, eyes
cans lead to perforation, haemorrhage, abcsess etc
if ulcers occur, stop treatment and consider alternative
name 3 long acting nitrates
- GTN patches
- isosorbide dinitrate MR (BD), isosorbide mononitrate BD
- MR isosorbide mononitrate OD
what type of drug is nicorandil
vasodilator
Non drug treatment that should be considered for patients with stable angina who remain symptomatic whilst on optimal drug therapy
revascularization by coronary artery bypass graft or percutaneous coronary intervention
Drugs for secondary prevention of CV disease (4)
Consider aspirin 75mg daily, taking into account risk of bleeding and comorbids
Consider ACEi for people with stable angina and diabetes
Offer stain treatment
Offer treatment for hypertension
Reviewing drug treatment - how often
Review pt response to treatment, including any SE, 2-4 weeks after starting or changing drug treatment
Titrate drug dosage against pt symptoms up to max tolerated dose
when to consider adding a 3rd anti anginal drug - only in the following situation!
Symptoms not satisfactory controlled with 2 anti anginal drugs AND
Pt waiting for recvascualrisation or revascularisation is not considered appropriate or acceptable
Decide which one to use based on comorbids, contraindications, pt pref and drug costs
Important note with ranolazine - it can cause the following
QT prolongation. So avoid with other drugs that cause this!
e.g. hypokalaemia: theophylline, b2 agonists, CCs, amphotericin B, loop and thiazide diuretics
e.g. QT interval: amiodarone, antipsychotics, apomorphine, citalopram, escitalopram, erythromycin , fluconazole, hydroxyzine, sotalol
avoid grapefruit juice with
ranolazine, other CCBs, ivabradine
it increases the exposure
max dose simvastatin with ranolazine
20mg
ivabradine can only be used in treatment of agina in pt with
normal sinus rhythm
ivabradine - avoid drugs that can increase the risk of
TDP
Also avoid potent inhibitors eg clarithromycin
monitoring for ivabradine
Monitor regularly for atrial fibrillation (consider benefits and risks of continued treatment if atrial fibrillation occurs).
Monitor for bradycardia, especially after any dose increase, and discontinue if resting heart rate persistently below 50 beats per minute or continued symptoms of bradycardia despite dose reduction.
important counselling info about nicorandil re a specific side effect (not ulceration)
headache more common on initiation
usually transitory
if they are suscepible to this, use lower inital dose regimen
Patient comes in complaining of stomach pain, they say they think it is a bad case of reflux. They also mention that they have got a few ulcers in their mouth that they want to buy bonjela for. They mention they are on medication for angina.
You tell them to stop taking this particular medication and urgently refer them to their GP. What medicine was it?
nicorandil
Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative.
which CCBs are licensed for angina. both RL and DHPDN
verapamil and diltiazem
nifedipine, nicardipine, amlodipine, felodipine
which drugs are CI if you take ivabradine etc
antipsychotics, amiodarone, apomorphine, citalopram, dronedarone, fluconazole - TDP - avoid
erythromycin, clarithromcyin - TDP and increases exposure to ivrabradine, avoid
