Angina

Question 1

Why does angina occur?

Answer 1

Narrowing of the coronary arteries reduces flow to myocardium (heart muscle). During times of high demand (exercise) there is insufficient blood supply to meet demand

Question 2

Typical symptoms?

Answer 2

Constricting chest pain - may radiate to jaw or neck

Question 3

What’s stable angina?

Answer 3

When symptoms relieved by rest OR glyceryl trinitrate (GTN)

Question 4

What’s unstable angina?

Answer 4

When symptoms come on at rest

Question 5

Which angina is a form of ACS?

Answer 5

Unstable angina

Question 6

Gold standard diagnostic investigation?

Answer 6

CT coronary angiography

Question 7

Baseline investigations?

Answer 7

• PE (HS, signs of HF, BMI)
• ECG
• FBC (anaemia can cause angina)
• U&Es
• TFTs (hypo/hyperthyroid)
• LFTs
• Lipid profile/cholesterol
• HbA1c + fasting glucose (for diabetes)

Question 8

When would you tend to measure U&Es in angina patients?

Answer 8

Prior to starting ACEi and other meds affecting kidney

Question 9

When would you measure LFTs for angina patients?

Answer 9

Prior to starting statins

Question 10

4 Principles of management?

Answer 10

RAMP:
R - Refer to cardiology (if unstable)
A - Advise them on diagnosis, management + when to call 999
M - Medical treatment
P - Procedural or surgical interventions

Question 11

3 aims of medical management?

Answer 11

1) immediate symptomatic relief
2) long term symptomatic relief
3) Secondary prevention of CVS disease

Question 12

Immediate symptomatic relief?

Answer 12

Glyceryl trinitrate (GTN) PRN:

• causes vasodilation
• take when symptoms start + repeat >5 mins if required: if there is still pain 5 mins after repeat dose CALL 999

Question 13

Long term symptomatic relief (anti-anginals)?

Answer 13

1) Beta-blocker (bisoprolol 5mg OD)

2) CCB (amlodipine 5mg OD) - ADD if not controlled

Question 14

Specialist long term symptomatic relief (anti-anginals)?

Answer 14

Long acting nitrates:

• isosorbide mononitrate
• ivabradine
• nicorandil
• ranolazine

Question 15

Secondary prevention?

Answer 15

4 A's: 
Aspirin (75mg OD)
Atorvastatin (80mg OD)
ACE inhibitor 
Already on a beta-blocker for symptomatic relief (add if on CCB?)

Question 16

When would you consider procedural/surgical intervention?

Answer 16

After 2 or more anti-anginals fail

Question 17

What would warrant a patient having a Percutanous Coronary Intervention (PCI)?

Answer 17

if CT coronary angiogram shows ‘PROXIMAL’ or ‘EXTENSIVE’ disease

Question 18

What would warrant a patient having a CABG?

Answer 18

If CT coronary angiogram shows severe stenosis

Question 19

CABG scar?

Answer 19

Midline sternotomy scar

Question 20

Which graft vein is usually taken from the leg to bypass stenosis?

Answer 20

Great saphenous vein

Question 21

Which veins are catheters for PCI inserted into?

Answer 21

Brachial & femoral

Question 22

What patients would you opt for a CABG > PCI?

Answer 22

Diabetics

valvular disease

Question 23

Which CCBs should you use for:

a) monotherapy
b) alongside beta-blocker

Answer 23

a) verapamil OR diltiazem (rate-limiting)

b) modified-release nifedipine, amlodipine (long acting)

Question 24

Which drugs in combination may cause heart block?

Answer 24

beta-blocker w/ verapamil OR diltiazem (rate-limiting)

Question 25

Steps to take if poor response?

Answer 25

1) increase long-term relief option to max tolerated dose (beta-blocker or CCB)
2) still poor response - add other long-term relief
3) if doesn’t tolerate/CI for CCB/beta-blocker:
- long-acting nitrate
- ivabradine
- nicorandil
- ranolazinee
4) if taking CCB + beta-blocker, consider 3rd drug whilst awaiting assessment for PCI/CABG

Question 26

Which medication commonly results in increased tolerance/reduced therapeutic effect?

Answer 26

Nitrates - commonly standard release isosorbide mononitrate

Question 27

Common SE of nicorandil?

Answer 27

GI ulcers (anywhere)! 
Diverticulitis patients have high risk of bowel perforation

Question 28

Medication that causes sexual dysfunction?

Answer 28

Beta-blockers

Question 29

Which treatment option for stable angina doesn’t improve survival?

Answer 29

PCI - does improve for ACS patients.

beta-blockers - improve survival if previous MI/HF