Angina

Question 1

What are the classification of Angina?

Answer 1

• Classical Angina
• Unstable angina
• Refractory Angina
• Vasospastic or Variant angina
• Microvascular Angina

Question 2

What is classical angina?

Answer 2

• Characterised by chest pain described as heavy, tight or gripping.
• Typically, pain is central/retrosternal and may radiate to jaw and/or arms.
• Pain tends to occur with exercise or emotional stress or when walking up close in cold weather and eases rapidly with rest

Question 3

What is Unstable Angina?

Answer 3

• Refers to angina of recent onset (<24h) or deterioration in previous stable angina with symptom frequently occurring at rest.
• Acute coronary syndrome

Question 4

What is Refractory Angina?

Answer 4

Patient with severe coronary disease in whom revascularization is not possible and angina not controlled by medical therapy

Question 5

NICE defines angina as:

Answer 5

1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes

Question 6

How do you label patient based on the NICE definition of Angina?

Answer 6

• Patients with all 3 features have typical angina
• Patients with 2 of the above features have atypical angina
• Patients with 1 or none of the above features have non-anginal chest pain

Question 7

What do you look for on examaination for Angina?

Answer 7

• S4 sound may be heard
• Sign suggesting anaemia, thyrotoxicosis or hyperlipidaemia (lipid arcus, xanthelasma, tendon xanthoma)

Question 8

What are diagnostic investigations of Angina?

Answer 8

1st Line: CT angiography

2nd Line: Non-invasive functional testing

• Use MPS with SPECT or Stress Echocardiography
• First pass contrast-enhanced magnetic resonance perfusion
• MRI for stress induced wall motion abnormalities

3rd Line: Invasive Coronary Angiography

Question 9

What are other investigations of Angina?

Answer 9

• Blood test
  
  • TFTs
  • Fasting Glucose, HbA1c
• Fasting Lipid Progile
• Glomerular Filtration
• Troponin if unstable
• 12 lead ECG
• Chest XR
• Echocardiography
• Diastolic Function, alternative causes to chest pain

Question 10

What agents are used for non-invasive functional testing?

Answer 10

• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT
• Adenosine or dipyridamole for first pass contract MR perfusion

Question 11

What is lifestyle advice for Angina?

Answer 11

• Exercise
• Smoking cessation
• Diet
• Weight control
• Psychological support and offer interventions if necessary

Question 12

How is symptomatic pain relief provided in Angina?

Answer 12

Offer a short-acting nitrate to prevent and treat episodes of angina

Question 13

What are the general guidelines of Angina treatment?

Answer 13

• One or Two anti-anginal drugs as necessary plus
• Drugs for secondary prevention of cardiovascular disease.

Question 14

What is the optimal drug treatment of Angina?

Answer 14

First line: Beta-blocker or Calcium Channel Blocker. Switch medication or use a combination of both if uncontrolled

If drugs are contraindicated or not tolerated, consider mono therapy or adding one drug using one of the following

• Long-acting nitrate (isorbide mononitrate)
• Ivabradine
• Nicorandil
• Ranolazine

Question 15

What is done for patients whose angina isn’t controlled by two anti-anginas drugs?

Answer 15

• Needs referral to cardiology
• Third Anti-anginal drug whilst awaiting specialist review

Question 16

When should third anti-anginas drugs be prescribed?

Answer 16

-The person’s symptoms are not satisfactorily controlled with two anti-anginal drugs and -The person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable.

Question 17

What is the secondary prevention of Angina?

Answer 17

• Consider Antiplatelet treatment in all people with stable angina taking into account the person’s risk of bleeding and co-morbidities. For most people this is low dose aspirin
• Consider treatment with an ACE inhibitor for people with stable angina and Diabetes mellitus
• Offer a Statin and Antihypertensive treatment

Question 18

When should revascularization be initiated?

Answer 18

• Consider in people whose stable angina is not controlled with optimal medical treatment.
• Offer coronary angiography to guide treatment strategy
• Treatment options:
  
  • Coronary artery bypass grafting
  • Percutaneous coronary intervention.

Question 19

When is CABG better?

Answer 19

CABG is better for patient who have multivessel disease that isn’t controlled with medical treatment and have:

• Diabetes or
• Are over 65 or
• Have anatomically complex three-vessel disease, with or without involvement of left main stem

Question 20

What should all patient with an NSTEMI receive?

Answer 20

• Aspirin 300mg
• Ticagrelor or Prasugrel
• Nitrates or Morphine to relieve chest pain if required

Question 21

What is antithrombin treatment for patients with NSTEMI?

Answer 21

• Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours.
• If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l, unfractionated heparin should be given.

Question 22

What should be given to patients who have intermediate or higher risk of adverse cardiovascular events and scheduled for angiography?

Answer 22

Intravenous glycoprotein IIb/IIIa receptor antagonists

• Eptifibatide
• Tirofiban

Question 23

When should coronary angiography be done in patients with NSTEMI?

Answer 23

Within 96 hours of first admission to hospital for patients with a predicted 6 month mortality above 3%

Question 24

What should be given to patients who have had a TIA to prevent further occlusive events?

Answer 24

1st line: Clopidogrel

2nd line: Aspirin & Dipyridamole

Both Lifelong

Question 25

What should be given to patients who have had an Ischaemic Stroke to prevent further occlusive events?

Answer 25

**1st line:** Clopidogrel **2nd line:** Aspirin & Dipyridamole Both Lifelong

Question 26

What should be given to patient who have had a diagnosis of peripheral arterial disease?

Answer 26

**1st line:** Clopidogrel **2nd line:** Aspirin Both Lifelong

Question 27

What should be given to patient who have had PCI?

Answer 27

Aspirin (lifelong) & prasurgrel or ticagrelor (12 months) If aspirin contraindicated, clopidogrel (lifelong)

Question 28

What should be given to patients with Acute Coronary Syndrome?

Answer 28

1st line: Aspirin (lifelong) & ticagrelor (12 months) If aspirin contraindicated, clopidogrel (lifelong)