Stable (Chronic) Angina - IHD/Coronary Heart Disease Flashcards
Background
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
Signs and Symptoms
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.
Diagnosis
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
Pharmacological Treatment
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
Secondary prevention for CV events
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
Treatment aims
- Immediate resolution of angina attacks (or prevention of predictable attacks using sublingual GTN).
- Decreasing the severity and/or frequency of angina attacks using anti-anginal drugs - beta-blockers, CCBs, long-acting nitrates or potassium channel activators.
- 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.