Angina pectoris and ACS

Question 1

What are the 3 features of anginal pain?

Answer 1

Constricting/heavy discomfort
Brought upon by exertion
Relieved by rest/GTN within 5 minutes

Question 2

What is the first line investigation for suspected stable angina?

Answer 2

Contrast enhanced CT angiography (NB also done if pain is non-anginal but ECG shows ischaemic change)

Question 3

What is the second line investigation for suspected stable angina?

Answer 3

Functional imaging e.g. stress echocardiogram or exercise ECG

Question 4

What is the third line investigation for suspected stable angina?

Answer 4

Invasive coronary angiography

Question 5

What time of the day should statins be taken?

Answer 5

Last thing in the evening

Question 6

What are the side effects of statins?

Answer 6

Myalgia/myopathy
Liver impairment
Possibly increased risk of intracerebral haemorrhage in patients who have previously had a stroke

Question 7

How do you check for liver impairment due to statins?

Answer 7

Check LFTs at baseline, after 3 months and after 12 months

Discontinue if transaminases rise and persist at 3x upper limit

Question 8

Give 3 contraindications of statins

Answer 8

Current use of macrolide antibiotics
Pregnancy, breastfeeding or 3 months before becoming pregnant
Previous intracerebral haemorrhage

Question 9

Give 4 side effects of nitrates

Answer 9

Hypotension
tachycardia
Headaches
Flushing

Question 10

Give 2 contraindications of nitrates

Answer 10

Aortic stenosis

Hypotension

Question 11

What is the first line anti-anginal medication for stable angina?

Answer 11

Either a beta blocker or CCB

Question 12

Give 2 indications for PCI/CABG in stable angina

Answer 12

Symptoms not satisfactorily controlled with optimal medical treatment
May gain survival benefit from surgery

Question 13

What ECG change suggests left main stem infarction?

Answer 13

ST elevation in aVR

Question 14

What are De Winter T waves?

Answer 14

In V1-4/5, upsloping ST depression followed by tall tented T waves (acute LAD occlusion)

Question 15

What is Wellen’s syndrome?

Answer 15

Ischaemic chest pain history plus biphasic or inverted T waves in V2-3 (critical LAD stenosis)

Question 16

What antiplatelets are given in non-STEMI ACS?

Answer 16

Aspirin
Clopidogrel/ticagrelor/prasugrel
Abciximab/eptifibatide if intermediate/high risk and scheduled for angiography within 24h

Question 17

What anticoagulation is given in non-STEMI ACS?

Answer 17

Fondaparinux or unfractionated IV heparin if angiography planned within 24h

Question 18

What antiplatelets are given in STEMI?

Answer 18

Aspirin and clopidogrel/ticagrelor/prasugrel

Question 19

What anticoagulation is given in STEMI?

Answer 19

LMWH or unfractionated IV heparin

Question 20

What are the indications for primary PCI in STEMI?

Answer 20

<12 hours onset and available within 120min

Question 21

What long term antiplatelet therapy is first line for MI?

Answer 21

Dual antiplatelet (aspirin + ticagrelor/prasugrel) for a year then aspirin indefinitely (+ gastric protection e.g. PPI);

Question 22

Occlusion of which coronary artery is associated with mitral regurgitation and heart block?

Answer 22

Right coronary artery

Question 23

What are the side effects of ivabradine?

Answer 23

Transient luminous phenomenon, bradycardia/heart block, headache

Question 24

What are the side effects of ranolazine?

Answer 24

Weakness, constipation, headache, vomiting

Question 25

What are the side effects of nicorandil?

Answer 25

Headache, flushing, anal ulceration