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Year 3 - CR > Stable Angina > Flashcards

Stable Angina Flashcards

1
Q

What are the causes of Angina?

A
  • Atheroma (most common cause)
  • Anaemia
  • Hypoxia
  • Tachyarrhythmias
  • HCM (increases oxygen demand)
  • aortic stenosis (increases oxygen demand)
  • arteritis/small vessel disease
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2
Q

What are the precipitants of Angina

A
  • Exertion
  • Emotion
  • Cold weather
  • Heavy Meals
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3
Q

Who does angina often occur in

A
  • Patients with Coronary artery disease involving at least one major epicardial artery
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4
Q

What is the pathophysiology of angia?

A
  • Due to myocardial ischaemia resulting in imbalance between oxygen supply and demand, this is brought about by exertion and relieved by rest
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5
Q

Define unstable Angina

A

Angina that presents in one of three principal ways

  • Occurs on minimal exertion or at rest
  • severe new onset angina
  • Angina of increasing severity and frequency
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6
Q

What is the diagnostic criteria for stable angina

A

Diagnostic criteria for stable angina
- Lasts 5-15 minutes
- Usually occurs with exertion or emotional stress
- Usually stops with rest or GTN spray
If you have all three features this is typical angina
If you have 2 out of 3 features this is atypical angina
If you have 0-1 of the features then this is non anginal chest pain

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7
Q

What is the decubitus Angina

A

Angina that is precipitated by lying flat

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8
Q

What is Prinzmetal Angina

A

Angina caused by coronary artery spasm

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9
Q

What is the difference in treatment between stable and unstable angina

A

Stable angina is treated medically whereas unstable angina is treated through PCI

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10
Q

What are the risk factors for Angina

A
  • Smoking
  • High cholesterol
  • No exercise
  • diabetes
  • hypertension
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11
Q

What are the signs and symptoms of Angina?

A
  • chest pain
  • pain that radiates to one or both arms, the neck, jaw or teeth
  • dyspnoea
  • Nausea
  • Sweatiness
  • Faintness
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12
Q

How do you diagnosed stable angina

A
  • History and physical examination
    • Diagnose according to diagnostic specification of angina
    • Blood tests - to identify conditions that make angina worse such as anaemia
    • Do an ECG to look for previous infarction
      ○ Previous infarction - pathological Q waves
      ○ LBBB
      ○ ST segment and T wave abnormalities
    • 1st line = CT coronary angiography
    • Non invasive
      ○ Myocardial perfusion scintigraphy (SPECT)
      ○ Stress echocardiography
      ○ MR perfusion
      ○ MR imaging for stress induced wall motion abnormalities
      Invasive coronary angiography as third line (gold standard) when previous two are inconclusvie
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13
Q

What is the 1st line test for diagnosing stable angina

A

CT coronary angiography

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14
Q

What is the gold standard for diagnosing stable angina

A

Invasive coronary angiography - only use when CT coronary angiography and non-invasive tests are inconclusive

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15
Q

Name the non-invasive tests looking for stable angina

A
  • Exercise ECG
  • myocardial perfusion scintigraphy (SPECT)
  • MR perfusion
  • MR imaging for stress induced wall motion abnormalities
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16
Q

Name the tests that look for coronary artery disease itself

A
  • CT calcium score and CT coronary angiography

- Invasive coronary angiogram

17
Q

What are the three types of treatment for stable angina

A
  1. PRN
  2. Anti-Anginal - prevent episodes of angina
  3. Secondary prevention treatment - prevent cardiovascular events such as heart attack and stroke - improve prognosis
18
Q

What are the types of stable angina medication that improves prognosis (secondary prevention treatment)

A
  1. Aspirin - 75mg daily for people with stable angina
  2. Statin - in line with NICE guideline on lipid modification
  3. ACE inhibitor - for people with stable angina and diabetes
  4. beta blocker if post MI
19
Q

How does secondary prevention treatment of angina improve cardiovascular outcome

A
  1. Aspirin - in patients with CVD reduces MI and stroke by 1/3rd and CV death by 1/6th
  2. statin - reduces death or MI by 25-30% in patients with CVD
  3. ACE inhibitor - reduces death, MI, or stroke by 20% in patients with CVD
  4. beta blocker if post MI
20
Q

What treatment is used in angina to improve symptoms

A
  1. Sublingual GTN

2. Beta blocker - 1st line anti-anginal therapy

21
Q

PCI has never been…

A

Show to improve outcome in stable angina

22
Q

What is the PRN treatment for Angina

A

GTN

  • Repeat dose after 5 minutes
  • Call ambulance if pain has not gone 5 minutes after taking second dose
23
Q

What is the 1st line anti-anginal medication for stable angina

A

Beta blockers or calcium channel blockers

24
Q

How do you treat stable angina surgically

A

Revascularisation
- Consider revascularisation or percutaneous coronary intervention (PCI) for people with stable angina whose symptoms are not controlled with optimal medical treatment

25
Q

What are the indications for referral for angina

A
  • diagnostic uncertainty
  • new angina of sudden onset
  • recurrent angina post MI or CABG
  • uncontrolled by drugs
  • unstable angina
26
Q

How do you treat stable angina medically (all together)

A
  • PRN = GTN
    ○ Repeat dose after 5 minutes
    ○ Call ambulance if pain has not gone 5 minutes after taking second dose
  • Secondary prevention treatment = prevent cardiovascular events such as heart attack and stroke
    ○ Aspirin 75mg daily for people with stable angina
    ○ ACE = for people with stable angina and diabetes
    ○ Statin treatment in line with NICE guideline on lipid modification
    ○ High blood pressure in line with NICE guideline on hypertension
    ○ Beta-blocker if post MI
    • Anti-anginal - to prevent episodes of angina
      ○ 1st line treatment
      § Beta blocker or calcium channel blocker
      ○ If persons symptoms are not controlled either
      § Switch to other option e.g. CCB if they are using BB
      § Or
      § Use combination
      □ When combining a CCB with a BB use a dihydropyridine calcium channel blocker (nifedipine, amlodipine or felodipine)
      ○ If person cannot tolerate beta blockers and calcium channel blockers or both a contraindicates consider monotherapy or combination (if using CCB or BB monotherapy) with
      § A long acting nitrate
      § Ivabradine
      § Nicorandil
      § Ranolazine
  • Add a third anti-anginal drug when
    ○ Persons symptoms are not controlled with two anti-anginal drugs and
    The person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable
27
Q

What is the side effect of GTN

A
  • headaches

- hypotension

28
Q

What medication do you have to have after a PCI

A

Dual antiplatelet therapy (DAPT; aspirin + clopidogrel) for 12months

29
Q

What are the complication of a PCI

A

haemorrhage, thrombosis, dissection, arterial spasm, angina, arrhythmias (usually transient), pericardial effusion, pericardial tamponade, infection

30
Q

What are the indications for CABG

A

improve survival: left main stem disease, triple-vessel disease involving proximal part of LAD; relieve symptoms: angina unresponsive to drugs, unstable angina, angioplasty unsuccessful

31
Q

what are the complication of CABG

A

– poor graft run-off, distal disease, new atheroma, graft occlusion, mood problems, sex problems, intellectual problems

32
Q

What investigations do you do for angina

-

A

Blood tests
- FBC, U+E, TFTs, lipids and HbA1c

Consider echo and CXR

If typical or atypical angina

  • 1st line - CT angiography
  • 2nd line - If inclusive then functional imaging
  • 3rd line – transcatheter angiography

Non anginal chest pain

  • Does the patient have ischaemic changes on 12 lead ECG
  • If yes – investigate as per typical and atypical angina
  • If no – no further investigations for IHD at this point
33
Q

How do you manage unstable angina

A

Unstable Angina: Early management
- Initial antiplatelet therapy - offer a 300mg loading dose of aspirin and continue aspirin indefinitely unless contraindicated
- Initial antithrombin therapy - offer fondaparinux unless high bleeding risk or immediate angiography
Then
Use established risk scoring system such as GRACE to predict 6-month mortality and risk of cardiovascular event

34
Q

What is included in the GRACE risk assessment for unstable angina

A

Includes in the risk assessment - clinical history, physical examination, resting 12-lead ECG and blood tests (troponin I or T, creatinine, glucose, haemoglobin

35
Q

What is the treatment for unstable angina if the GRACE risk assessment predicts a low risk mortality

A
  • Consider conservative management without angiography but be aware that some younger people may benefit from early angiography
    • Offer ticagrelor with aspirin unless high bleeding risk
    • Consider clopidogrel with aspirin or aspirin alone, for high bleeding risk
    • Consider ischaemia testing before discharge
      Consider angiography (with follow-on PCI if indicated) if ischaemia develops or shown on testing)
36
Q

Expand on the anti-anginas medication used

A
  • Use either a beta blocker or a calcium channel blocker first line based on comorbidities, contraindications and persons preference
  • If calcium channel blocker is used as a monotherapy – a rate limiting one such as verapamil or diltiazem should be used
  • If the calcium channel blocker is used in combination with a beta blocker then use a long acting dihydropyridine calcium channel blocker such as Nifedipine
  • VERAPAMIL SHOULD NOT BE PRESCRIBED WITH BETA BLOCKERS – leads to complete heart block
  • If a patient is symptomatic after monotherapy with a beta blocker add a calcium channel blocker and vis versa
  • If a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or beta blocker then consider one of the following drugs either a long acting nitrate, ivabradine, nicorandil or ranolazine
  • If a patient is taking both a beta blocker and a calcium channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG
37
Q

What is the treatment for unstable angina if the GRACE risk assessment is high (greater than 3%)

A

Then if immediate or high risk (predicted 6 month morality >3%)
- Offer immediate angiography if clinical condition unstable
- Otherwise consider angiography with follow-on PCI if indicated within 72 hours if no contraindications such as comorbidity or active bleeding
- If no separate indication for oral anticoagulation offer prasugrel once PCI intended
- Offer systemic unfractionated heparin in catheter laboratory if having PCI
- Offer a drug-eluting stent if stenting indicated
If follow-on PCI not done, consider angiography findings, comorbidities and risks and benefits when discussing management strategy with the interventional cardiologists, cardiac surgeon and the patient

38
Q

What should verapamil never be prescribed with

A
  • VERAPAMIL SHOULD NOT BE PRESCRIBED WITH BETA BLOCKERS – leads to complete heart block

Year 3 - CR (44 decks)

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