angina and heart attacks

Question 1

what is stable angina

Answer 1

• predictable chest pain/pressure, often precipitated by physical exertion or emotional stress which causes increase in myocardial oxygen demand
• relieved within a few mins of resting

Question 2

stable angina usually results from

Answer 2

atherosclerotic plaques in coronary arteries which restrict blood flow and oxygen supply to heart

Question 3

describe the pain in stable angina

Answer 3

• typically occurs in front of chest
• can spread to neck, jaw, left arm, shoulder

Question 4

complications of stable angina

Answer 4

• unstable angina
• stroke
• MI
• sudden cardiac death

Question 5

Prinzmetals or vasospastic angina

Answer 5

• rare form of angina, not caused by atherosclerosis
• caused by narrowing or occlusion of proximal coronary arteries due to spasm
• pain is experienced at REST

Question 6

how to treat acute attacks of stable angina

Answer 6

• sublingual GTN

Question 7

How to use sublingual GTN for the treatment of angina

Answer 7

• one tab/1-2 sprays under tongue and close mouth
• dose may be repeated at 5 min intervals if needed
• seek urgent medical care if symptoms not resolved 5 mins after second dose, or earlier if pt unwell/pain is intensifying
• max 3 doses

Question 8

how to use sublingual GTN for angina prophylaxis

Answer 8

1 tablet/400–800 micrograms to be administered under the tongue and then close mouth prior to activity likely to cause angina.

Question 9

long term prevention of chest pain in pt with angina

Answer 9

1. BB (or RL-CCB instead)
2. dual therapy of BB + any CCB licensed (if they are taking BB, prescribed DHPN CCB e.g. amlod, felod, MR nifed)

avoid verap + BB same time - significant interaction, increased risk adverse CV events

3. if either BB or CCB cannot be given, add vasodilator as dual therapy (LA nitrate, ivabradine, nicorandil, ranolazine)
4. if both BB and CCB can’t be given, vasodilator mono therapy (LA nitrate, ivabradine, nicorandil, ranolazine)

Question 10

4 BB that are licensed for angina long term treatment - PBAM

Answer 10

propranolol
bisoprolol
atenolol
metoprolol

Question 11

Can you give BB in Prinzemtal’s angina

Answer 11

no it is contraindicated! give RL-CCB instead e.g. verapamil or diltiazem
DHPRDN-CCB e.g. amlodipine may also be effective

Question 12

What is used for treatment of Prinzmetals angina

Answer 12

NOT BB they are contraindicated!!

RL CCB or DHPDN CCB e.g. amlodipine

Question 13

MOA nitrates

Answer 13

• potent coronary vasodilators
• reduce venous return to heart, thus reduce LV work (blood pumped out by heart) = less CO = less strain on heart

Question 14

Examples of vasodilators that can be used in angina long term prevention therapy (e..g if a BB or CCB not suitable)

Answer 14

Long acting nitrate (e.g. isosorbide mono/dinitrate), ivabradine, nicorandil, ranolozine

Question 15

Cautions nitrates - long acting or transdermal preps

Answer 15

• many pt taking these quickly develop tolerance
• constant levels of nitrates in blood = body becomes desensitised
• progressively higher dose needed for same therapeutic effect
• to overcome, choose dose timings that leave blood nitrate free or with very low levels for 4-12 hours everyday
• e.g. remove patches for 8-12h (e.g. overnight)
• when a LA nitrate taken BD, take 2nd dose after 8 h instead of 12 hours so it doesn’t cover a 24h period
• MR isosorbide mononitrate to be taken OD

Question 16

SE of nitrates

Answer 16

• vasodilators: flushing, throbbing headache, postal hypotension

Question 17

interactions of nitrates

Answer 17

• SE if hypotension, so taking two or more drugs = increased risk of hypotension
• e.g. antihypertensives, alpha blockers, BBs, antidepressants, antipsychotics, diuretics, SGLT2i (e.g. canag)
• e.g. SEVERE, avoid phosphodiester-type 5 inhibitors (e.g. sildenafil)

Question 18

when to assess response to treatment

Answer 18

• every 2-4 weeks after initiation or change of drug therapy
• titrate drug doses to max tolerated effective dose

Question 19

when to refer to specialist

Answer 19

• combination of two drugs at max therapeutic doses fail to control angina symptoms

Question 20

does having angina put you at increased risk of CV events

Answer 20

yes

Question 21

secondary prevention of CV events

Answer 21

• lifestyle factors e.g. smoking cessation, weight management, increase physical activity
• all pt with arable angina due to atherosclerotic disease should be given long term treatment with lose dose aspirin + statin
  consider ACEi also esp if pt has diabetes

Question 22

how long does the effects of sublingual GTN last

Answer 22

provides rapid symptomatic relief, but effect only lasts 20-30 mins

Question 23

expiry of sublingual GTN tablets

Answer 23

8 weeks after opening!!

Question 24

MHRA nicorandil

Answer 24

ulcers of mouth, mucosa, GI, eyes
cans lead to perforation, haemorrhage, abcsess etc
if ulcers occur, stop treatment and consider alternative

Question 25

name 3 long acting nitrates

Answer 25

- GTN patches - isosorbide dinitrate MR (BD), isosorbide mononitrate BD - MR isosorbide mononitrate OD

Question 26

what type of drug is nicorandil

Answer 26

vasodilator

Question 27

Non drug treatment that should be considered for patients with stable angina who remain symptomatic whilst on optimal drug therapy

Answer 27

revascularization by coronary artery bypass graft or percutaneous coronary intervention

Question 28

Drugs for secondary prevention of CV disease (4)

Answer 28

Consider aspirin 75mg daily, taking into account risk of bleeding and comorbids Consider ACEi for people with stable angina and diabetes Offer stain treatment Offer treatment for hypertension

Question 29

Reviewing drug treatment - how often

Answer 29

Review pt response to treatment, including any SE, 2-4 weeks after starting or changing drug treatment Titrate drug dosage against pt symptoms up to max tolerated dose

Question 30

when to consider adding a 3rd anti anginal drug - only in the following situation!

Answer 30

Symptoms not satisfactory controlled with 2 anti anginal drugs AND Pt waiting for recvascualrisation or revascularisation is not considered appropriate or acceptable Decide which one to use based on comorbids, contraindications, pt pref and drug costs

Question 31

If both PCI and CABG is appropriate for the patient and they do not have a preference, which one would you select

Answer 31

- PCI more cost effective - potential survival advantage of CAPBG for pt with multi vessel disease whose symptoms are not satisfactorily controlled with optimal med and who have diabetes OR over 65 OR anatomically complex three vessel disease with or without involvement of the left mainsteam

Question 32

Important note with ranolazine - it can cause the following

Answer 32

QT prolongation. So avoid with other drugs that cause this! e.g. hypokalaemia: theophylline, b2 agonists, CCs, amphotericin B, loop and thiazide diuretics e.g. QT interval: amiodarone, antipsychotics, apomorphine, citalopram, escitalopram, erythromycin , fluconazole, hydroxyzine, sotalol

Question 33

avoid grapefruit juice with

Answer 33

ranolazine, other CCBs, ivabradine it increases the exposure

Question 34

max dose simvastatin with ranolazine

Answer 34

20mg

Question 35

ivabradine can only be used in treatment of agina in pt with

Answer 35

normal sinus rhythm

Question 36

ivabradine - avoid drugs that can increase the risk of

Answer 36

TDP

Question 37

monitoring for ivabradine

Answer 37

Monitor regularly for atrial fibrillation (consider benefits and risks of continued treatment if atrial fibrillation occurs). Monitor for bradycardia, especially after any dose increase, and discontinue if resting heart rate persistently below 50 beats per minute or continued symptoms of bradycardia despite dose reduction.

Question 38

important counselling info about nicorandil re a specific side effect (not ulceration)

Answer 38

headache more common on initiation usually transitory if they are suscepible to this, use lower inital dose regimen

Question 39

Patient comes in complaining of stomach pain, they say they think it is a bad case of reflux. They also mention that they have got a few ulcers in their mouth that they want to buy bonjela for. They mention they are on medication for angina. You tell them to stop taking this particular medication and urgently refer them to their GP. What medicine was it?

Answer 39

nicorandil Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative.

Question 40

which CCBs are licensed for angina. both RL and DHPDN

Answer 40

verapamil and diltiazem nifedipine, nicardipine, amlodipine, felodipine

Question 41

which drugs are CI if you take ivabradine etc

Answer 41

antipsychotics, amiodarone, apomorphine, citalopram, dronedarone, fluconazole - TDP - avoid erythromycin, clarithromcyin - TDP and increases exposure to ivrabradine, avoid