Stable Angina

Question 1

What causes stable angina

Answer 1

Imbalance between blood supply and demand
Myocardial ischaemia NOT infarction
Narrowing of artery worse on exertion as increased demand
ALWAYS relieved by rest or GTN in contrast to unstable which comes on at rest

Question 2

What causes decreased blood supply and what worsens

Answer 2

Atherosclerosis >70%
Spasm
Inflammation

Worsens

• Anaemia
• Hypertension
• Tachycardia / AF
• Hyperthyroid

Question 3

What causes increased oxygen demand

Answer 3

Activity / stress
Increases HR and contractibility
or LVH as requires more O2

Question 4

What are RF for angina

Answer 4

Age
Male 
Smoking 
DM
Hypertension
Hyperlipidaemia
Anaemia
Hyperthyroid 
Obesity 
Exercise
Diet

Question 5

What are the symptoms of angina

Answer 5

Chest pain - heavy / tight / gripping 
Radiate down T1-T4 (left arm + jaw) 
Worse exertion / stress 
SOB on exertion 
Fatigue on exertion
Near syncope 
N+V / tachycardia / diaphoresis - increased sympa

Question 6

What makes angina worse

What makes angina better

Answer 6

Worse on exertion / stress

GTN / rest improves

Question 7

What makes angina unlikely

Answer 7

Sharp stabbing
No pattern
Comes on after exercise
Lasts hours 
Palpitations
Tingling 
Dizzy

Question 8

What are signs of associated conditions

Answer 8

Pallor of anaemia
Hypertension 
Tachycardia 
Systolic murmor - AS / MR
Crackles / elevated JVP / oedema = HF

Question 9

What are signs on examination

Answer 9

Tar staining
Obesity
Corneal arcus
Hypertension
AAA
Arterial bruit
Reduced pulses
Retinopathy

Question 10

What are the differentials for angina

Answer 10

MI / ACS
Aortic dissection
Pericarditis
Pneumonia
PE
Pneumothorax
Epigastric pain / dyspepsia 
MSK 
Anxiety

Question 11

How do you classify severity of angina

Answer 11

1 = only on exertion 
2 = slight limitation of activity
3 = marked limitation 
4 = symptoms on any activity

Question 12

When can angina present without pain

Answer 12

Elderly

DM

Question 13

How do you investigate angina

Answer 13

CVS exam 
Bloods
- FBC - anaemia
- U+E - drugs e.g. ACEI
- LFT - statin
- Lipids - RF
- HbA1c and fasting glucose - RF
- TFT - linked 
TROPONIN
ECG 
Consider a CXR for other causes

Question 14

What are the signs of angina on ECG / ETT

Answer 14

ST depression + T wave inversion during an attack - mild ischarmic changes
May show prior MI (Q waves) or LVH (ST depression)

Question 15

How do you further investigate angina

Answer 15

CT / invasive angiography - show if CAD and decide whether medication, PCI or CABG
Non-invasive functioning imaging

Question 16

What are non invasive functional imaging options

Answer 16

ETT = 1st line (resting + exercise ECG)
Symptoms + ECG changes when exercise

Myocardial perfusion imaging
Image on rest then drug to stress heart + image
Infarct if no image even at rest, ischaemia if no image on stress

Cardiac MRI

Question 17

When is ETT harder to do

Answer 17

Pregnancy
High BP
Elderly
CI in aortic stenosis

Question 18

What are general measures in stable angina

Answer 18

Stop smoking
Control BP
Control DM
Lifestyle
Treat anaemia, thyroid, tachycardia

Question 19

What is prognostic / 2 prevention which everyone should receive unless CI

Answer 19

Aspirin 75mg daily
Statin 80mg
ACEI - stabilise
BB but likely already on

Question 20

What is symptomatic treatment

Answer 20

GTN every 5 minutes causes vasodilatation
Repeat
If still pain after repeat dose = call an ambulance

Question 21

What is prophylactic treatment

Answer 21

BB (reduce HR and demand)

CCB - relax coronary / contration / vasodilataion

Question 22

What do you do if not controlled

Answer 22

Use rate limiting CCB if mono therapy but change to vasodilator if dual
Increase to dose
Dual therapy
Add on a third whilst waiting for surgery

Question 23

What are 3rd line options

Answer 23

Nicorandil - vasodilator K activation
Ivabradine - reduce SA node rate
Long acting nitrate (isosorbide mononitrate)

Question 24

What does Ivabradine do

Answer 24

Slows diastolic depolarisation reducing Hr and O2 demand
Only use if HR >70
Use if can’t tolerate BB

Question 25

What must you exclude as a cause of angina

Answer 25

Aortic stenosis

Question 26

What are surgical options

Answer 26

CABG

PCI

Question 27

What are SE of GTN

Answer 27

Headache
Hypotension
Flushing
Tachycardia

Question 28

What are SE of Ivabradine

Answer 28

Metabolised by p450
Visual
Brady
Headache

Question 29

When is nicorandil CI and what are SE

Answer 29

LV failure / pulmonary oedema
Hypotension
Hypovolaemia

SE
Headache
Flushing
Anal ulceration

Question 30

What can you develop with nitrates

Answer 30

Tolerance
Only seen in long acting
Reduce time between dose

Question 31

What does PCI do

Answer 31

Dilate artery using balloon and insert stent
Do at angiography if extensive disease
Use femoral / radial / brachial

Question 32

What must you continue after PCI

Answer 32

Dual anti-platelet 12 months

Question 33

PCI or CABG

Answer 33

PCI higher risk of restenosis but lower adverse risks

Question 34

When is CABG used

Answer 34

Left main stem
Triple vessel including LAD
Abnormal LV

Question 35

Benefits of CBAG

Answer 35

Lasts longer
Less revasculisation
Open heart surgery
Saphenous vein used to bypass

Question 36

When is surgery indicated

Answer 36

Angina unresponsive to medical Rx
Unstable angina
Unsuccessful PCI

Question 37

When do you refer to cardiology

Answer 37

Routine if stable

Urgent if unstable

Question 38

What do you look for in examination

Answer 38

Sternotomy suggesting CABG or scar on inner calf where vein harvested
Scar in femoral or brachial for PCI