Stable (Chronic) Angina - IHD/Coronary Heart Disease

Question 1

Background

Answer 1

Symptoms only tend to occur in patients that have significant stenosis (narrowing) of a coronary artery

Permanent restriction of blood flow causes a mismatch between the supply and the demand of oxygenated blood to the myocardium at times of stress or activity when cardiac output (CO) increases.

Relieved by:
Ceasing activity or
GTN

Question 2

Signs and Symptoms

Answer 2

Retrosternal chest heaviness
Radiation to back/arms/neck/jaw
Associated breathlessness
Autonomic symptoms (tachycardia/sweating/pallor/)

Stable angina vs ACS (UA, NSTEMI/STEMI) difference is stable angina responds to GTN and symptoms are predictable.

Question 3

Diagnosis

Answer 3

Detailed clinical history and physical examination
- Typicality.
Typical angina – 3 features
Atypical angina – 2/3 features
Non anginal chest pain 0/1 features

Features:
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 minutes.

Tests:
12 Lead ECG or
64 slice or CT coronary angiography

Question 4

Pharmacological Treatment

Answer 4

ACUTE ATTACKS:
Sublingual GTN = Rapid relief of symptoms of angina and for use before performing activities known to cause symptoms

Preventer treatment:
1st line - Beta-blocker
ALT rate limiting CCB (Diltiazem, Verapamil).
- Can combo but consider other CCB in combo (nimodipine etc) BC D/V with B blocker can cause HF, Bradycardia, asystole. IF not possible try combo with 1 of the 2nd line drugs.

NOTE: B-Blocker contraindicated in unstable HF OK with stable HF (used for CHF)
- ALT CCB
(Other b-blocker contraindications: decompensated HF, Prinz metal angina. asthma, severe COPD)
- Dihydropyridine CCB (eg amlodipine) can be useful in Prinz metal angina

2nd line - ADD/ALT Long acting nitrate (Isosorbide mononitrate, Isosorbide dinitrate), Nicorandil, Ivabradine, Ranolazine.
- if MAX tolerated/licensed isn’t working try different drug from 2nd line
- When adding 1 of the above you remove either CCB or B-blocker if that combo already in use. SO KEEP AT 2 DRUGS!

3rd line - Consider starting 3rd anginal drug whilst waiting for specialist

MANAGE co Morbid conditions

Question 5

Secondary prevention for CV events

Answer 5

People with angina assumed to have high CV risk.

Lifestyle changes
- smoking cessation,
- weight management,
- increased physical activity
- reduce alcohol intake
Psychological support

DRUGS
Long term treatment with low dose aspirin (75mg)
- Stroke or peripheral arterial disease PT should be on clopidogrel already so continue on this.

Start a statin.

Consider ACEi esp. If diabetic.
/other Antihypertensive (to control bp) BP needs to be elevated

ALSO MANAGE CO MORBID conditions

Question 6

Treatment aims

Answer 6

1. Immediate resolution of angina attacks (or prevention of predictable attacks using sublingual GTN).
2. Decreasing the severity and/or frequency of angina attacks using anti-anginal drugs - beta-blockers, CCBs, long-acting nitrates or potassium channel activators.
3. Providing secondary prevention treatment as the patient by definition has existing cardiovascular disease in the form of antiplatelet therapy, high intensity statins and ACEi

• non drug treatment includes surgery only done if on optimal drugs but still suffering with stable angina.