stable angina

Question 1

what is stable angina?

Answer 1

chest discomfort provoked by effort or emotion and relieved by rest

Only radiated symptoms may be experienced such as isolated throat tightness or arm heaviness.

Question 2

what does angina usually reflect?

Answer 2

• coronary artery disease

however, can also indicate

• aortic stenosis
• hypertensive heart disease
• hypertrophic cardiomyopathy

Question 3

what would you pay close attention to in an examination for angina?

Answer 3

• weight and height to calculate BMI (or waist/hip ratio)
• blood pressure
• presence of murmurs, especially that of aortic stenosis
• evidence of hyperlipidaemia
• evidence of peripheral vascular disease and carotid bruits (especially in diabetes)

Question 4

what investigations should be done in a patient presenting with angina?

Answer 4

• FBC and biochemical screen including glucose/HbA1c
• full lipid profile
• resting 12 lead ECG for info on rhythm, presence of heart block, previous MI and myocardial hypertrophy and ischaemia

Question 5

what increases likelihood for angina?

Answer 5

• diabetes
• smoking
• hyperlipidemia

Question 6

if likelihood of coronary artery disease is 61-90%, what should be offered?

Answer 6

invasive coronary angiography

Question 7

if likelihood of CAD is 30-60%, what should be offered?

Answer 7

functional imaging as first line diagnostic investigation (stress MRI, echo or myoview)

Question 8

if likelihood of CAD is 10-29% what should be offered?

Answer 8

CT calcium scoring as first line diagnostic investigation (CT measures calcium level). if score is 0 = minimal likelihood of significant coronary disease.

if the score is 1-400, consideration should be given to CTCA or stress perfusion imaging Above 400, coronary angiography should be considered.

Question 9

how are patients with angina treated with drugs?

Answer 9

• aspirin 75mg OD
• if they can’t take aspirin, clopidogrel 75mg OD
• sublingual GTN spray
• symptom control with B blockers.
• rate limitation in patient with normal chronotropic response to exercise, best achieved with B blockers and non dihydropyridine CCB e.g diltiazem or verapamil.
• long acting nitrates and K cannel opening drugs are effective for vasodilation
• Statin
• ACE inhibitor

Question 10

what can be given if a b blocker is not appropriate or tolerated?

Answer 10

ivabradine 5-7.5mg BD, a sinus node blocking agent.

not for angina where HR is below 70 bpm.

also don’t co prescribe with diltiazem or verapamil

Question 11

what is the use of ranolazine?

Answer 11

for patients who are inadequately controlled or intolerant to first line drugs

baseline 375mg BD to max of 750mg BD

use for patients with chronic stable angina, rather than an acute setting.

can only be prescribed by consultant

Question 12

what are some non cardiac causes of chest pain?

Answer 12

1) costochondritis
2) GORD
3) PE
4) Pneumonia
5) pneumothorax
6) psychogenic/psychosomatic