Week 5/6 - C - Angina and Acute Coronary Syndrome (Unstable angina, N.S.T.E.M.I, S.T.E.M.I) - Symptoms, Diagnosis, Treatment COPY

Question 1

What is chronic stable angina? What is a common name for this?

Answer 1

Chronic stable angina is a symptomatic reversible myocardial ischaemia due to fixed stenosis of the coronary artery usually because of coronary atherosclerosis Common name is exertional angina as it is induced by effort

Question 2

What are the features of typical stable angina?

Answer 2

Typical stable angina * Constricting/heavy discomfort to the chest, jaw, neck, shoulder or arms * The symptoms are brought on by exertion * The symptoms are relieved within 5 minutes by rest or GTN spray

Question 3

What is acute coronary syndrome? What are the spectrum of conditions that this provisional diagnosis covers?

Answer 3

Acute coronary syndrome is the acute presentation of coronary artery disease The provisional diagnosis includes: * Unstable angina * NSTEMI * STEMI

Question 4

How long does the atherosclerosis process take? What are different risk factors for atherosclerosis?

Answer 4

Aterosclerosis is a process tht takes place over years due to endothelial injury because of risk factors such as hypertension, hyperlipidaemia, diabetes, smoking, alcohol Eventually the plaque may rupture and cause acute blockage of the artery - thrombosis can occur here due to platelets/fibrin clot

Question 5

Describe the difference between a stable angina attack and acute coronary syndrome?

• * Main symptoms
• * Duration
• * Onset
• * Relieved by
• * Associated symptoms

Answer 5

Both

• * Main symptoms - Constricting/heavy discomfort to the chest, jaw, neck, shoulders or arms
• * Associated symptoms - sweating, nausea, vomiting, dyspnoea
• Stable angina - duration less than 10 minutes, onset due to exertion and relieved by GTN spray or rest
• Acute coronary syndrome - Last longer than 30 minutes, often occurs at rest, GTN spray has no effect

Question 6

What is the variant of angina pectoris that occurs at night while the patient is recumbent known as?

What causes this variant?

Answer 6

Angina decubitus is a variant of angina pectoris that occurs at night while the patient is recumbent - this indicates unstable angina

Some have suggested that it is induced by an increase in myocardial oxygen demand caused by expansion of the blood volume with increased venous return during recumbency.

• (recumbent means lying flat)
• (decubitus means lying down)

Question 7

STABLE ANGINA

Typical stable angina

• * Constricting/heavy discomfort to the chest, jaw, neck, shoulder or arms
• * The symptoms are brought on by exertion
• * The symptoms are relieved within 5 minutes by rest or GTN spray

A diagnosis of stable angina can be excluded if clinical assessment indicates non-anginal chest pain What would indicate non-anginal chest pain?

Answer 7

Non-anginal chest pain - 0 or 1 of

• Constricting/heavy discomfort to the chest, jaw, neck, shoulder or arms
• The symptoms are brought on by exertion
• The symptoms are relieved within 5 minutes by rest or GTN spray

Question 8

Tests carried out in a patient with potential ischaemic heart disease are usually ECG Blood tests What may be seen on the ECG in stable angina?

Answer 8

12 lead ECG may be normal but may show * ST depression, flat or inverted T wave indicating a past MI or ischaemia * Pathological Q waves may be present also indicating past MI (any Q waves seen in V1-3 and Q waves >1.5mm in other leads)

Question 9

What blood tests are carried out in investigating a patient with stable angina?

Answer 9

Full blood count - anaemia can worsen angina Lipid profile Hb1ac - check glucose levels for diabetes Measure TFTs

Question 10

Further investigations after the blood tests and ECG may be considered to diagnose ischaemic heart disease What do these include?

Answer 10

An exercuse ECG - assesses for ischaemic ECG changes CT angiography - allows visualisation of coronary artery stenosis

Question 11

What is the treatment of angina? * Secondary prevention * Treatment for symptoms relief * Anti-anginal medication

Answer 11

SABA (statin, ACE, BBlocker, Aspirin) Secondary prevention * Aspirin * Statin eg atorvastatin * ACE inhibitor if diabetes co-morbidity Symptom relief * Prescribe subliingual GTN for rapid relief Anti-anginal medication * Prescribe BBlocker (usually) or CCB as 1st line regular treatment

Question 12

Prescribe a beta-blocker or a calcium-channel blocker (CCB) as first-line regular treatment to reduce the symptoms of stable angina, Give examples of both drug types? How do they help the heart?

Answer 12

BBlockers eg atenolol or bisoprolol - reduce heart rate and force of contraction Calcium channel blockers eg amlodopine (dihydropyridine) - vasodilators or verapamil, dilitiazem (rate limiting) - prolong AP decreasing heart rate

Question 13

Why should a beta blocker not be given with a rate limitng CCB?

Answer 13

Do not combine BBlockers and rate limiting CCB as this can cause severe bradycardia or heart block

Question 14

If both beta-blockers and CCBs are contraindicated or not tolerated, consider monotherapy with one of the following drugs. What are the options?

Answer 14

Monotherapy * Long acting nitrate - isosorbide mononitrate * Ivabradine * Nicorandil * Ranolazine

Question 15

What is the mechanism of action of the second line anti-anginal treatments? * Isosorbide mononitrate * Ivadbradine * Nicorandil * Ranolazine

Answer 15

Isosorbide mononitrate - nitrates increase NO therefore relaxing smooth muscle Ivadbradine - prolongs diastolic activity by selectively and specifically inhibiting the funny current Nicorandil - potassium channel opener promoting K+ efflux cause hyperpolarisation - relaxes smooth muscle Ranolazine - inhibits sodium channel

Question 16

What are the side effects of the different drugs? Which drug forms a tolerance? * Isosorbide mononitrate - nitrates increase NO therefore relaxing smooth muscle * Ivadbradine - prolongs diastolic activity by selectively and specifically inhibiting the funny current * Nicorandil - potassium channel opener promoting K+ efflux cause hyperpolarisation - relaxes smooth muscle * Ranolazine - inhibits late sodium channel

Answer 16

Side effects * Nitrates (increases NO)- headaches, hypotension, tolerance can build if repeated adminsitration so leave 8hr/day free period * Ivabradine (inhibits funny current)- altered visual disturbance * Nicoradnil (potassium channel opener increase K+ efflux) - headache, mouth/GI ulcers * Ranolazine (inhibits late sodium channel) - dizziness, constapation

Question 17

In patients with continued unacceptable angina despite maximal medical therapy, what may be considered?

Answer 17

Coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) Difficult to decide between the two

Question 18

ACUTE CORONARY SYNDROME When are people usually suspected with having acute coronary syndrome?

Answer 18

* Patients who have the onset of pain at rest or on minimal exertion * The pain lasts longer than 30 minutes * It is not relieved by rest or GTN spray These people will usually require referral or admission to hospital

Question 19

What tests are carried out to confirm the diagnosis of acute coronary syndrome in a patient? What is the difference in the two tests between he three different conditions in ACS?

Answer 19

Patient undergoes a 12-lead ECG and a blood testis taken for high-sensitivity troponin STEMI - ECG shows ST elevation and troponin positive NSTEMI - ECG does not show ST elevation but troponin positive Unstable angina - ECG does not show ST elevation and troponin negative

Question 20

What are the ECG changes that may be seen in acute STEMI?

Answer 20

Acute STEMI Hyperacute tall T waves St elevation, * (>/=1mm ST elevation in 2 adjacent limb leads) * (>/=2mm ST elevation in at least 2 contiguous precordal leads) T wave inversion, Qwaves New onset left bundle branch block

Question 21

What are the ECG changes that may be seen in NSTEMI and Unstable angina? Why is troponin not raisied in unstable angina?

Answer 21

ECG changes will not show ST elevation May show ST depression, T wave inversion indicating ischamia Tropnonin is released when there is myocardial cell death - it is not released in unstable angina as the ischaemia did not cause permanent cell damage

Question 22

What are the different types of troponin and which are the cardiac specific troponin levels measured in suspected ACS?

Answer 22

There is Troponin C - calcium binding site (pulls troponin tropmyosin complex apart exposing actin filaments for actin-myosin cross bridge linking) - identical in heart and skeletal muscle TROPNIN I (inhibits actin-myosin interactions) and TROPONIN T (facilitates contraction) are the cardiac specific troponin isoforms

Question 23

ACS management depends on whether the ACS is ‘ST elevated’ or not Urgent revascularisation management is very important in a STEMI What qualifies for urgent revascularisation management of a STEMI?

Answer 23

STEMI - urgent revascularisation essential Chess pain suggestive of acute MI ECG changes showing one of * Acute STEMI * >/=1mm in two contiguous limb leads * >/=2mm in two contigous chest leads New onset LBBB Posterior MI (ST depression in V1-V3)

Question 24

STEMI What is the initial management of a patient presenting with an acute STEMI?

Answer 24

Initial management is to attach a 12 lead ECG, gain IV access to take bloods (FBC, U&Es, lipids, troponin, gluocse) Take a brief assessment and examination Give * Morphine (+ anti-emetic eg metoclopramide) * Oxygen if breathless or low sats * Nitrates - sublingual GTN * Aspirin + * Clopidogrel, prasgruel or ticagrelolor

Question 25

After patient has had the initial management, brief assessment has been taken and the ECG shows one of: Acute STEMI * >/=1mm in two contiguous limb leads * >/=2mm in two contigous chest leads New onset LBBB Posterior MI (ST depression in V1-V3) What is the preferred method revasuclarisation and when can it be carried out? What is the alternative?

Answer 25

Preferred method revascularisation is primary PCI with angiographic identification * Should be offered to all patients who present within 12 hours of symptoms onset and who can be transferred to a primary PCI centre within 120 minutes of STEMI diagnosis * If patient presents within 12 hours and cannot be transferred to a primary PCI centre within 120 minutes of diagnosis, they should recieve thrombolysis

Question 26

What are the different choice of thrombolytic that the patient can be given? What is given to the patient with STEMI who does not recieve perfusion? ie presents >12 hours after symptom onset

Answer 26

Thrombyltic therapy - alteplase, teneplase, streptokinase If patient presents >12hours after symptom onset, give fondaparinux or LMWH/unfractioned heparin

Question 27

UNSTABLE ANGINA / NSTEMI What is the intiial management of all patients with confirmed unstable angina / NSTEMI?

Answer 27

INitial management Morphine (+anti-emetic), oxygen, nitrate aspirin, Clopidogrel/prasgruel/tricagrelor Give fondaparinux or enoxaparin (LMWH)/unfractioned heparin until dishcarge Give BBlocker and ACEi

Question 28

The treatment of an NSTEMI differs depending on the calculation of the risk stratification score What score is used to calculate a patients 6 month mortality risk who presents with unstable angina / NSTEMI?

Answer 28

Calculated the patient’s GRACE score (Global Registry of Acute Cardiac Events) This calculated score predicts the patients 6-month mortality score to categorise the risk of future adverse cardiovascular events as follows

Question 29

What is the management for a patient who has a low risk of adverse coronary vascular advents from a GRACE score?

Answer 29

Offer conservative management without early coronary angiography to patients with a low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less).

Question 30

What is the management options for a patient who has a greater than or equal to intermediate risk of adverse coronary vascular advents from a GRACE score? (>3%)

Answer 30

* Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity)

Question 31

What is the drug class given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission? Give example drug

Answer 31

Intravenous glycoprotein IIb/IIa receptor antagonisits are given to these patients - eg Abciximab, eptifibatide, tirofiban

Question 32

What are the cardioprotective mechanisms given after an acute coronary syndrome event?

Answer 32

SABA + * High dose statin * ACE inhibitor * Beta blocker - if contraindicated consider rate limiting CCB * Aspirin and second anti-platelet for at least 12 months (P2Y12 receptor antagonist)