Stable Angina

Question 1

Angina risk factors

Answer 1

Non-modifiable:

· Age

· Male

· Family history of IHD – MI in 1st degree relative <55 years

Modifiable

· Smoking

· Hypertension

· Hypercholesterolaemia

· Diabetes

· Obesity

· Previous MI, CABG or stent

Question 2

Ix Angina

Answer 2

initially

1. 12-lead resting ECG
2. Bloods - troponin T/I and creatine kinase (if current chest pain), FBC (anaemia), U&E’s (ACEi), LFTs (statin), TFTs, HBA1c (diabetes) and biochemical screen including glucose and HBaC1, ESR (arteritis)
3. Full lipid profile

Question 3

Confirm a diagnosis of stable angina and follow the recommendations in managing stable angina when: (2)

Answer 3

1. Significant coronary artery disease is found during invasive or CT coronary angiography
2. Reversible myocardial ischaemia is found during non-invasive functional imaging

Question 4

Examination of Angina

Answer 4

1. weight and height (BMI)
2. blood pressure
3. CVS exam> murmors
4. hyperlipidemia signs (xanthelasma, Xanthoma, corneal arcus)
5. look for previous surgical scars

Question 5

Advice (GP) for angina

Answer 5

Factors that can provoke angina (4 E’s)

• Exertion
• Emotional stress
• Exposure to cold
• Eating a large meal

Address implications for daily activities

• Many people can continue to work as before
• If job involves heavy manual work, they may need to alter their work practices
• If their job involves driving, consult the DVLA
• If they have an occupational health department, consult them

Question 6

medications for Angina

Answer 6

1. Secondary prevention of CVS disease

Lifestyle advice – stop smoking, exercise, good diet, optimise hypertension and diabetes control

• 75mg aspirin daily if not contraindicated (clopidegrol if allergic)
• Address hyperlipidaemia and hypertension (statins)
• Consider ACE inhibitors if they have diabetes

2. PRN symptom relief

• Glyceryl trinitrate (GTN) spray or sublingual tablets.
• Advice patient to repeat the dose if the pain persists within 5mins and to call 999 if the pain is still present 5mins after the second dose
• tell them that SE can be : light headed, flushy, dizzy (so sit down shwaya)

3. Anti-anginal medication

• Beta-blockers /Ca2+ channel blockers
• Long acting nitrate e.g. isosorbide mononitrate if above not tolerated
• Ivabradine – if blood pressure drops (ib B-blocker contraindicated or not toleraed) DO NOT PRESCRIBE WITH VERAPIMIL)

4. Revascularisation – optimal medical therapy proves inadequate

o PCI

o CABG

Question 7

Secondary prevention treatment – to prevent CVS events such as MI/stroke (4As)

Answer 7

• Anti-platelet treatment taking into account bleeding risk and comorbidities – aspirin
• ACEi if stable angina and diabetes mellitus
• Statin – atorvastatin
• Anti-hypertensive treatment if appropriate

Question 8

Referral angina?

Answer 8

Hospital admission

1. Pain at rest
2. Pain on minimal exertion
3. Angina progressing rapidly despite medical treatment

Refer to cardiologist for angiography and possible revascularisation (CABG/PCI) if:

1. Extensive ischaemia on ECG
2. Angina persists despite optimal drug treatment

Question 9

Follow-up angina

Answer 9

Review response to treatment including any adverse effects 2-4 weeks after starting or changing drug treatment

Question 10

How can you calculate an individual’s risk of ACS, when do u give statin?

Answer 10

QRISK

1. If QRISK2 >10%, first offer lifestyle advice.
2. Then offer statin.