Angina

Question 1

Angina

Answer 1

Retrosternal chest discomfort related to ischaemic heart disease

Stable
- Lasts <= 10 mins and subsides with rest
- Pattern of symptoms has not changed during the past month.

Differential
- Anaemia, valvular heart disease.

Review for co-morbidities
- Anaemia, aortic stenosis, thyrotoxicosis, hypertrophic cardiomyopathy

Management
1 - Optimal management of underlying coronary artery disease
- Smoking cessation
- HTN
- Dyslipidaemia
- Exercise (150mins cardio / week)
- BMI 18-25
- DM control

2 - Management of acute angina episode
- GTN spray 400-800microg subling Q5mins up to 3 doses.
- GTN tablet 300-600microg subling Q5mins up to 3 doses.
If pain > 10 mins despite 2 doses, take 3rd dose and call ambulance (?ACS)

3 - Angina prevention
- Two antianginal therapies from different classes
- Beta blockers 1st line
- Metoprolol tartrate 25mg PO BD
- Atenolol 25mg PO OD
- HFrEF? Use HF beta blocker (Cravedilol, Nebivolol, Bisoprolol, Metoprolol Succinate)

• Dihydropyridine Ca Channel blocker
  
  • Amlodipine 2.5mg PO OD
  • Nifedipine MR 30mg PO OD
  • Beta blocker contraindicated and No heart failure?
    
    • Can consider non-dihydropyridine Ca channel blocker
      
      • Diltiazem MR 180mg PO OD
      • Verapamil MR 120mg PO OD
        Do not use with combination of beta blocker because of risk of severe bradycardia and heart failure.
• Long-acting Nitrate
  
  • Can be added to non-dihydropyridine calcium channel blocker or beta blocker.
  • Allow for nitrate free period to reduce risk of nitrate tolerance.
  • GTN Patch 5mg Transdermal OD. Apply for max 14 hours in 24 hour period.
  • Isosorbide mononitrate MR 30mg PO OD.
• Refractive to above?
  
  • Nicroandil 5mg PO OD. Can bee added to beta-blocker or non-dihydropyridine ca channel blocker

Non-pharmacological Management in Angina
- Psychologist for CBT
- ACAT to review home support services
- Cardiac Rehabiliation programs
- Moderate intensity exercise 150mins / week.