Angina

Question 1

What are common cardiac causes of chest pain?

Answer 1

• acute coronary syndrome (unstable angina, NSTEMI, STEMI)
• acute aortic dissection
• thoracic aortic aneurysm
• stable angina
• pericarditis / myocarditis
• mediastinitis
• arrhythmia
• cardiac tamponade
• mitral valve prolapse

Question 2

What are common respiratory causes of chest pain?

Answer 2

• pneumonia
• pneumothorax (simple/tension)
• viral pleuritis
• pulmonary embolism
• lung cancer
• mesothelioma
• COPD / Asthma
• acute resp distress syndrome (ARDS)
• pleural effusion
• empyema
• interstitial lung disease
• lung abscess

Question 3

What are common gastrointestinal causes of chest pain?

Answer 3

• GORD
• oesophagitis
• oesophageal rupture
• acute abdomen

Question 4

What are common musculoskeletal causes of chest pain?

Answer 4

• trauma (ribs/muscular/soft tissue) -> flail chest, fracture etc
• costochondritis
• viral infection of muscles
• muscle strain
• smoker’s cough
• isolated MSK chest pain syndrome
• connective tissue disease

Question 5

Any other (non-cardiac, -resp, -GI) causes of chest pain?

Answer 5

• panic attack
• psychogenic chest pain
• recreational drug induced
• medication-related
• herpes zoster

Question 6

What are the 3 features of typical angina?

Answer 6

1. Constricting/heavy discomfort to the chest, jaw, neck, shoulders or arms
2. Symptoms brought on by exertion/stress
3. Symptoms relieved within 5min by rest or GTN

all 3 features = typical angina, 2 features = atypical angina and 0-1 features = non-anginal chest pain

Other associated symptoms: dyspnoea, nausea, sweating, faintness

Question 7

What investigations are important for angina?

Answer 7

• ECG at rest shows ST depression, during an attack shows T wave flattening or inversion - must be repeated to show dynamic changes
• stress/exercise ECG
• haemoglobin -> anaemia
• myocardial perfusion imaging (inject dobutamine + thalium scan)
• stress echo
• coronary artery angiogram is diagnostic (gold std) - undertake in pts with a positive stress test or negative stress test but with symptoms

Question 8

What are risk factors for coronary artery disease/angina?

Answer 8

• age (>= 55yrs men, >= 65yrs women)
• smoking
• diabetes mellitus
• dyslipidaemia
• FHx of premature CVD (ages above)
• hypertension
• obesity
• kidney disease (microalbuminuria or GFR<60)
• physical inactivity

Question 9

The initial management and secondary prevention of stable angina is conservative treatment. What does this involve?

Answer 9

• stop smoking
• exercise
• dietary advice
• optimise hypertension + DM control
• 75mg aspirin if not contraindicated
• address hyperlipidaemia -> statins?
• consider ACE inhibitors, eg. if diabetic

Question 10

What is the symptomatic relief treatment of angina?

Answer 10

• glyceryl trinitrate (GTN) spray or sublingual tabs
• two sprays or tablets under tongue to be repeated as required
• advice pt to repeat dose if pain has not gone after 5min
• administration prior to to exercise that induces angina will provide better relief than administration after pain onset
• pt should avoid using GTN for >16hr / day to prevent development of resistance to drug

Question 11

What is the medical management of chronic angina?

Answer 11

• first line: B-blocker and/or ca-ch blocker
• b-blockers - atenolol, bisoprolol
• calcium antagonists - amlodipine, diltiazem
• long-acting nitrates - isosorbide mononitrate
• ivrabradine
• ranolazine
• nicorandil

Question 12

If optimal medical therapy proves inadequate, what’s next?

Answer 12

REVASCULARISATION

• PCI - balloon inflated inside stenosed vessel, opening lumen. Stent usually inserted to reduce risk of re-stenosis. Dual antiplatelet therapy (clopidogrel + aspirin) recommended for at least 12/12 after stent insertion to reduce risk of stent thrombosis
• CABG - pts undergoing this less likely to need repeat revascularisation and those with multivessel disease can expect