Stable Angina Flashcards
What are the causes of Angina?
- Atheroma (most common cause)
- Anaemia
- Hypoxia
- Tachyarrhythmias
- HCM (increases oxygen demand)
- aortic stenosis (increases oxygen demand)
- arteritis/small vessel disease
What are the precipitants of Angina
- Exertion
- Emotion
- Cold weather
- Heavy Meals
Who does angina often occur in
- Patients with Coronary artery disease involving at least one major epicardial artery
What is the pathophysiology of angia?
- Due to myocardial ischaemia resulting in imbalance between oxygen supply and demand, this is brought about by exertion and relieved by rest
Define unstable Angina
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
What is the diagnostic criteria for stable angina
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
What is the decubitus Angina
Angina that is precipitated by lying flat
What is Prinzmetal Angina
Angina caused by coronary artery spasm
What is the difference in treatment between stable and unstable angina
Stable angina is treated medically whereas unstable angina is treated through PCI
What are the risk factors for Angina
- Smoking
- High cholesterol
- No exercise
- diabetes
- hypertension
What are the signs and symptoms of Angina?
- chest pain
- pain that radiates to one or both arms, the neck, jaw or teeth
- dyspnoea
- Nausea
- Sweatiness
- Faintness
How do you diagnosed stable angina
- 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
What is the 1st line test for diagnosing stable angina
CT coronary angiography
What is the gold standard for diagnosing stable angina
Invasive coronary angiography - only use when CT coronary angiography and non-invasive tests are inconclusive
Name the non-invasive tests looking for stable angina
- Exercise ECG
- myocardial perfusion scintigraphy (SPECT)
- MR perfusion
- MR imaging for stress induced wall motion abnormalities
Name the tests that look for coronary artery disease itself
- CT calcium score and CT coronary angiography
- Invasive coronary angiogram
What are the three types of treatment for stable angina
- PRN
- Anti-Anginal - prevent episodes of angina
- Secondary prevention treatment - prevent cardiovascular events such as heart attack and stroke - improve prognosis
What are the types of stable angina medication that improves prognosis (secondary prevention treatment)
- Aspirin - 75mg daily for people with stable angina
- Statin - in line with NICE guideline on lipid modification
- ACE inhibitor - for people with stable angina and diabetes
- beta blocker if post MI
How does secondary prevention treatment of angina improve cardiovascular outcome
- Aspirin - in patients with CVD reduces MI and stroke by 1/3rd and CV death by 1/6th
- statin - reduces death or MI by 25-30% in patients with CVD
- ACE inhibitor - reduces death, MI, or stroke by 20% in patients with CVD
- beta blocker if post MI
What treatment is used in angina to improve symptoms
- Sublingual GTN
2. Beta blocker - 1st line anti-anginal therapy
PCI has never been…
Show to improve outcome in stable angina
What is the PRN treatment for Angina
GTN
- Repeat dose after 5 minutes
- Call ambulance if pain has not gone 5 minutes after taking second dose
What is the 1st line anti-anginal medication for stable angina
Beta blockers or calcium channel blockers
How do you treat stable angina surgically
Revascularisation
- Consider revascularisation or percutaneous coronary intervention (PCI) for people with stable angina whose symptoms are not controlled with optimal medical treatment
What are the indications for referral for angina
- diagnostic uncertainty
- new angina of sudden onset
- recurrent angina post MI or CABG
- uncontrolled by drugs
- unstable angina
How do you treat stable angina medically (all together)
- 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
- Anti-anginal - to prevent episodes of angina
- 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
What is the side effect of GTN
- headaches
- hypotension
What medication do you have to have after a PCI
Dual antiplatelet therapy (DAPT; aspirin + clopidogrel) for 12months
What are the complication of a PCI
haemorrhage, thrombosis, dissection, arterial spasm, angina, arrhythmias (usually transient), pericardial effusion, pericardial tamponade, infection
What are the indications for CABG
improve survival: left main stem disease, triple-vessel disease involving proximal part of LAD; relieve symptoms: angina unresponsive to drugs, unstable angina, angioplasty unsuccessful
what are the complication of CABG
– poor graft run-off, distal disease, new atheroma, graft occlusion, mood problems, sex problems, intellectual problems
What investigations do you do for angina
-
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
How do you manage unstable angina
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
What is included in the GRACE risk assessment for unstable angina
Includes in the risk assessment - clinical history, physical examination, resting 12-lead ECG and blood tests (troponin I or T, creatinine, glucose, haemoglobin
What is the treatment for unstable angina if the GRACE risk assessment predicts a low risk mortality
- 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)
Expand on the anti-anginas medication used
- 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
What is the treatment for unstable angina if the GRACE risk assessment is high (greater than 3%)
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
What should verapamil never be prescribed with
- VERAPAMIL SHOULD NOT BE PRESCRIBED WITH BETA BLOCKERS – leads to complete heart block
