Stable Angina

Question 1

What are the 3 features of stable angina?

Answer 1

• Constricting discomfort to chest, jaw, neck, shoulders, arms
• Sx brought on by exertion
• Sx relieved by rest/GTN

Sx last about 10mins per episode

Question 2

What are the 4 types of angina?

Answer 2

• Stable angina
• Unstable angina
• Decubitus angina - percipitated by lying flat
• Variant (Prinzmetal) angina - caused by coronary artery spasm

Question 3

What are the causes of angina?

Answer 3

• Atheroma (common)
• Rare
  
  • coronary artery spasm
  • AS
  • Severe ventricular hypertrophy

Question 4

What Ix would you order for stable angina?

Answer 4

• Bedside
  
  • ECG
• Bloods
  
  • FBC, U&E, LFT
  • Lipid, HbA1C
• Imaging
  
  • CXR
  • Echo
  • CT Coronary angiography
• Special test
  
  • Exercise ECG (no longer used)

Question 5

What is the Mx for stable angina?

*remember RAMP

Answer 5

• Refer to Cardiology if unstable angina
• Advise about diagnosis, mx and when to call ambulance
• Medical tx
• Proceural intervention

Question 6

What medications are used for stable angina?

think immediate relief, long term relief, secondary prevention

Answer 6

• Symptomatic immediate relief
  
  • GTN
    
    • Repeat after 5mins
    • Call ambulance if pain still persist after 5mins
• Long term symptomatic relief
  
  • Beta blocker
    
    • Atenolol 50mg BD
    • Bisoprolol 5-10mg OD
  • CCB
    
    • Amlodipine 5mg OD
  • Isosorbide Mononitrate
  • Nicorandil
  • Ivabradine - if LVF
  • Ranolazine
• Secondary prevention
  
  • Aspirin 75mg OD
  • Artovastatin 80mg OD
  • ACEi

Question 7

What are the procedural interventions for stable angina?

Answer 7

• Percutaneous coronary intervention
  
  • aspirin + clopidogrel for at least 12months
  • femoral artery access scar
• CABG
  
  • for severe stenosis
  • mid sternotomy scar

Question 8

What are the other options for long term symptomatic relief?

Answer 8

• Long acting nitrates (e.g. isosorbide mononitrate)
• Ivabradine
• Nicorandil
• Ranolazine

Question 9

What is a charactersitic of Prinzmetal angina?

Answer 9

• pain occurs during rest, resolves rapidly with GTN
• ECG: ST elevation

Question 10

What are the features of unstable angina?

Answer 10

• occurs at rest or minimal exertion
• increase in severity or frequency
• onset within 1month

Question 11

What are the features of concerning chest pain?

Answer 11

• Chest pain lasts > 10 minutes
• Chest pain not relieved by two doses of GTN taken 5 minutes apart
• Significant worsening/deterioration in angina (e.g. increased frequency, severity or occurring at rest)

Question 12

How would you grade angina using the Canadian cardiovascular Society?

Answer 12

• Grade I: angina with strenuous activity (e.g. limitation on strenuous or prolonged ordinary activity).
• Grade II: angina with moderate activity (e.g. slight limitation if normal activities performed rapidly).
• Grade III: angina with mild exertion (e.g. difficulty climbing one flight of stairs at normal pace).
• Grade IV: angina at rest (e.g. no exertion needed to trigger).

Question 13

Describe the pretest probability of CAD base on typical sx, age, sex and RF

Answer 13

• If estimated likelihood of CAD is 61-90%
  
  • offer invasive coronary angiography
• If estimated likelihood of CAD is 30-60%
  
  • offer functional imaging (stress MRI, echo or myoview)
• If estimtaed likelihood of CAD is 10-29%
  
  • offer CT calcium scoring
    
    • <1: minimal likelihood of CAD
    • 1-400: CTCA
    • >400: Coronary angiography
• If man >70 c typical or untypical sx: assume CAD likelihood >90%
• if women > 70 c typical or untypical sx: assume CAD likelihood 61-90%
• If women at high risk and typical sx: CAD likelihood >90%

Question 14

What are the examples of non cardiac chest pain?

Answer 14

• Costochondritis
• GORD
• PE
• Pneumonia
• Pneumothorax
• Psychogenic/psycosomatic