Stable angina

Question 1

Which is the more common condition - stable or unstable angina?

Answer 1

Stable angina.

Question 2

What type of therapy should be prescribed to all patients?

Answer 2

Anti-platelet therapy.

Question 3

Who is affected the most?

Answer 3

Men - esp older than 60 years.

Question 4

What does angina pectoris result from?

Answer 4

An imbalance between myocardial oxygen supply and demand.

Question 5

Myocardial oxygen supply is determined by what 2 factors?

Answer 5

1. Coronary blood flow.

2. Arterial oxygen content.

Question 6

What is the prognosis for SA?

Answer 6

· With aggressive lifestyle modification and medical therapy, patients can expect a reduction in anginal symptoms.

· With this, patients can expect to be free of angina within 1 year.

Question 7

What is the aetiology of SA?

Answer 7

· Atheromatous plaque leading to obstruction of coronary blood flow is the most common cause.

· Ischaemic symptoms may result from obstruction of blood flow due to atherosclerotic plaques.

Question 8

List some of the potential risk factors?

Answer 8

· Advancing age.
· Smoking. 
· HTN. 
· Elevated LDL. 
· Diabetes.
· Inactivity. 
· Obesity. 
· FH of premature ischaemic heart disease. 
· Illicit drug use. 
· Male sex.

Question 9

What are the 3 typical angina symptoms?

Answer 9

1. Chest pressure or squeezing lasting several minutes.
2. Provoked by exercise or emotional stress.
3. Relieved by rest of GTN.

Question 10

What groups of people may present with atypical angina symptoms?

Answer 10

Women, diabetics and older people.

Question 11

What are atypical angina symptoms?

Answer 11

Chest discomfort and 2 of the following:

1. Chest pressure or squeezing lasting several minutes.
2. Provoked by exercise or emotional stress.
3. Relieved by rest of GTN.

Question 12

What investigations would you request if you suspected a patient had SA?

Answer 12

· Resting ECG. 
· Haemoglobin. 
· Fasting lipid profile. 
· Fasting blood glucose or HbA1c. 
· TSH. Hyperthyroidism can exacerbate angina. Hypothyroidism is associated with dyslipidaemia and IHD. 
· Stress exercise ECG without imaging. 
· Coronary angiography.

Question 13

What typically would a resting ECG show in SA?

Answer 13

Often normal but may reveal ST or T wave changes suggestive of ischaemia.

Question 14

Why are haemoglobin levels measured?

Answer 14

Severe anaemia may cause angina without obstructive coronary lesions.

Question 15

Why are TSH levels measured?

Answer 15

Hyperthyroidism can exacerbate angina. Hypothyroidism is associated with dyslipidaemia and IHD.

Question 16

List some differentials.

Answer 16

· Aortic dissection. 
· Pericarditis.
· PE.
· Pneumothorax.
· Oesophagitis.
· Oesophageal spasm. 
· GORD.
· GI complaints.

Question 17

What is the treatment for all patients?

Answer 17

· 1st - Lifestyle education.
· Plus - Anti-platelet therapy: aspirin or clopidogrel.
· Adjunct - Anti-anginal therapy: bisoprolol.
· Adjunct - Statin.
· Adjunct - ACEi or ARB.
· Adjunct - Blood sugar control.
Adjunct - Revascularisation.

Question 18

What is the treatment option for patients with acute anginal symptoms?

Answer 18

Normal treatment plus sublingual GTN.

Question 19

What drugs contraindicate sublingual GTN?

Answer 19

Phosphodiesterase inhibitors.

Question 20

What complications can occur?

Answer 20

· Chronic heart failure.
· MI.
· Acute stroke.
· Depression.

Question 21

What is the difference between stable and unstable angina attacks?

Answer 21

Stable - more common - attacks have a trigger (stress/exercise) + stop within a few minutes of resting.

Unstable - more serious - attacks are more unpredictable - may not have a trigger + continue despite resting.