Stable angina & ACS

Question 1

What are the features of angina?

Answer 1

Constricting/heavy discomfort in chest, neck, jaw, shoulder or arm

Symptoms brought on by exertion

Symptoms relieved within 5 minutes by GTN

Question 2

What is the difference between typical and atypical angina?

Answer 2

typical = all 3 features of angina

atypical = only 2 features of angina

Question 3

What is the difference of stable and unstable angina?

Answer 3

Stable angina = induced by effort, relieved by rest

Unstable angina = angina of increasing frequency or severity, occurs on minimal exertion or at rest, and is associated with increased risk of MI

Question 4

What investigations would you perform in stable angina?

Answer 4

Cardio examination

Bloods:
FBC - check for anaemia
U&Es - prior to starting on ACE inhibitors
LFTs - prior to starting on statins
TFTs - check for hypo/hyperthyroidism
Lipid profile
HbA1c and fasting glucose - for diabetes

ECG - usually normal

Echo

CXR

Question 5

What is the management for angina?

Answer 5

GTN for PRN symptomatic relief

Anti-anginal medication:
1st line = beta-blocker (e.g. atenolol) or calcium channel blocker (e.g. amlodipine, verapamil, diltiazem)
If patient is still symptomatic using mono therapy, add a calcium channel blocker or beta-blocker (DO NOT give verapamil with beta-blocker due to increased risk of heart block)
If can’t tolerate addition of either of these medication then consider either isosorbide mononitrate (a long-acting nitrate), ivabradine, ranolazine, nicrorandil

Question 6

What do patients taking nitrates have to be wary of?

Answer 6

Nitrates tolerance and reduced efficacy

This is not seen in patients who take once-daily modified-release isosorbide mononitrate

Question 7

What investigations should be carried out in suspected ACS?

Answer 7

Bloods:
FBC, U&Es, glucose, lipids
Troponin - IMMEDIATELY!

ECG - IMMEDIATELY!

CXR
Echo
CT coronary angiogram

Question 8

What ECG and troponin findings would indicate STEMI, NSTEMI and unstable angina?

Answer 8

Troponin +ve with ST elevation or new onset LBBB = STEMI

Troponin +ve with ST depression, inverted T waves, non-specific changes, or looks normal = NSTEMI

Normal troponin and no ECG changes = unstable angina

Question 9

What is the management for ACS?

Answer 9

For all patients with ACS (MONA mnemonic):
Morphine 
Oxygen - if SaO2 <94%
Nitrates
Aspirin 300mg

STEMI:
2nd anti platelet e.g. clopidogrel or ticagrelor
Beta-blocker
ACEi/ARB
insulin if hyperglycaemic
PPCI - should be done within 2 hours of presentation
Thrombolysis - if unable to perform PPCI within 2 hours of presentation

NSTEMI or unstable angina:
Beta-blocker
Eptifibatide or tirofiban (both are glycoprotein IIb/IIa inhibitors) with unfractionated heparin can be given to patient wit unstable angina or NSTEMI with high risk of MI or death