Angina + heart attack

Question 1

What are the symptoms of stable angina?

Answer 1

Chest pain (tight, dull heavy)
- Relieved w few mins of rest

Radiates to left arm, neck + jaw

Question 2

Which drugs are used for stable angina?

Answer 2

Short-acting nitrate

• Glyceryl trinitrate (Sublingual tab: 8 week expiry)
• Isosorbide dinitrate

Long-acting nitrate

• GTN (transdermal)
• Isosorbide dinitrate MR (last 12h: BD)
• Isosorbide mononitrate (MR: OM)

Beta-blocker

Dihydropyridine calcium channel blocker

Vasodilator

• Ivabadrine
• Ranolazine

Question 3

What is used to treat an acute attack of stable angina?

Answer 3

GTN

• Lasts 20-30 min
• Take during attack or before exertion
• Route: sublingual spray/tablet
• Sit down. 1 dose. Repeat 5 min intervals
• 999 rule: Call if symptoms don’t resolve after second dose

Question 4

What is used as first line prophylaxis of stable angina?

Answer 4

First line: Beta-blocker

Alt (asthmatic): calcium channel blocker (diltiazem)

Question 5

What is used as second line prophylaxis of stable angina?

Answer 5

beta-blocker AND Dihydropyridine calcium channel blocker

• AVOID verapamil + beta-blocker → INC risk of HF
• If both drugs CI: vasodilator monotherapy (long acting nitrate, ivabadrine, ranolazine, nicorandil)

Question 6

What is the MHRA warning of nicorandil?

Answer 6

skin, mucosa + eye ulcer

Question 7

What is the MOA of nitrates?

Answer 7

• Potent coronary vasodilator
• RED venous return, left ventricular work tf cardiac output

Question 8

How do you prevent tolerance to nitrates?

Answer 8

• Leave patch off for 8-12h (GTN)
• Take 2nd dose after 8h not 12 (Isosorbide dinitrate MR (BD), Isosorbide mononitrate (BD))
• Take MR isosorbide mononitrate OD

Question 9

What are the side effects of nitrates?

Answer 9

Flushing, throbbing headache, postural hypotension - vasodilation

Question 10

What are the interactions of nitrates?

Answer 10

Hypotension:
- Phosphodiesterase-type 5 inhibitor: sildenafil
- Antihypertensives
- Anti-depressants
- Anti-parkinsonian
- Anti-psychotics
- Diuretics
- SGLT2i

Question 11

What is the secondary prevention for NSTEMI + STEMI?

Answer 11

High intensity statin

ACEi

Beta-blocker

Dual antiplatelet therapy:
- Low dose aspirin (for life) AND
- Clopidogrel OR rivaroxoban (12M)

Question 12

What is the treatment for unstable angina + NSTEMI?

Answer 12

• Aspirin 300mg (chew or disperse in water)
• GTN (S/L PRN)

Question 13

What is the treatment for a STEMI?

Answer 13

• Aspirin 300mg (chew or disperse in water)
• GTN (S/L PRN)
• ADD IV diamorphine/morphine AND metoclopromide
• Oxygen if needed

Question 14

What is percutaneous coronary intervention?

Answer 14

short wire mesh tube (stent) put in permanently to open up a coronary artery, allowing blood to flow more freely

Offer dual antiplatelet: Aspirin (indefinitely) OR

Clopidogrel (stable angina)
- Bare metal stent: 1M
- Drug eluting stent: 6M (high risk of clots)

Question 15

What is the treatment for a cardiac arrest?

Answer 15

CPR: 100 - 200 times per min

• 30 compressions
• 2 breaths

IV adrenaline

IV amiodarone
- Treat ventricular fibrillation, pulseless ventricular tachycardia