Stable Angina

Question 1

Definition?

Answer 1

Pain or discomfort in chest, shoulders, neck or jaw caused by insufficient blood supply to myocardium-usually occurs predictably with physical exertion for no more than 10 mins and is relieved within minutes of rest.

Question 2

Risk factors?

Answer 2

• Older
• Male
• CVD risk factors
• CAD

Question 3

Ddx?

Answer 3

• ACS
• Aortic Dissection-tearing chest pain radiating to shoulder blades
• Pericarditis-sharp pain and SOB relieved on sitting forward
• Acute CHF
Arrhythmias

Question 4

Epidemiology?

Answer 4

Age: Elderly
Sex: Male
Ethnicity:
P: CHD causing angina accounted for 45% deaths in 2014

Question 5

Aetiology?

Answer 5

• Atheroma
• AS
• Anaemia
• Tachyarrhythmias
• Small vessel disease

Question 6

CP?

Answer 6

• Precipitated by physical exertion
• Discomfort in neck, chest, jaw, or arms
• Relieved by GTN
• GI discomfort
• SOB
• N and V
• Sweatiness
• Faintness

Question 7

Pathophysiology?

Answer 7

• Reduced blood flow->70% stenosis-blocked by plaque in coronary arteries
• In exercise or stress the heart works harder and can’t meet the demands metabolic of the myocardium
• Hypertrophic cardiomyopathy-thickened muscle wall needs more oxygen
• Pump against high pressure-HT and aortic stenosis
• Sub-endocardium ischaemia-stimulates adenosine and bradykinin irritates sensory/pain neurones

Question 8

Investigations-first line?

Answer 8

CVS and resp exam and history

Question 9

Investigations-second line?

Answer 9

ECG (ST depression)and CT angiography and full bloods to investigate causes/complications

Question 10

Investigations-third line?

Answer 10

Invasive coronary angiography and functional imaging tests eg exercise ECG

Question 11

Management-first line?

Answer 11

GTN before planned exertion

Drug treatment/secondary prevention of CVD

Question 12

Drug treatment line?

Answer 12

First line: CCB or BB
Second line: Swap
Third line: Use combined
Fourth line:
• a long-acting nitrateor
• ivabradineor
• nicorandilor
• ranolazine.

Question 13

Drugs for prevention lines?

Answer 13

Aspirin 75mg daily
ACEi if diabetes too
Rivaroxaban if
• aged 65 or over, or
• atherosclerosis in at least 2 vascular territories (such as coronary, cerebrovascular, or peripheral arteries), or
• 2 or more of the following risk factors:
• current smoking
• diabetes
• kidney dysfunction with aneGFRof less than60 ml/min(note that rivaroxaban is contraindicated if the eGFR is less than15 ml/min)
• heart failure
previous non-lacunar ischaemic stroke

Question 14

Management second line?

Answer 14

CABG-if coronary angiography indicates left main stem disease or proximal three-vessel disease.

PCI

Question 15

Management third line?

Answer 15

Offer re-evaluation
Consider cardiac syndrome X
Myocardial perfusion scintigraphy
Pain Managment-spinal cord stimulation

Question 16

Complications?

Answer 16

• Stroke
• MI
• Unstable angina
• Sudden cardiac death
• Anxiety and depression
• Reduced quality of life

Question 17

Prognosis?

Answer 17

This varies on CAD prognosis, LV function, exercise duration and comorbidities and progression since time seen.