Angina Pectoris

Question 1

When is chest discomfort experienced in patients with angina?

Answer 1

On exertion or emotional stress

Question 2

What causes the discomfort patients with angina experience?

Answer 2

One exertion the oxygen demand of the myocardium increases. Due to a narrowed lumen the flow of of the blood cannot adequately increase to meet the demands of the myocardium and this leads to the production of lactic acid- this is what causes the discomfort. It is called demand ischaemia

Question 3

How can the the cause of angina be subdivided?

Answer 3

Atherosclerotic disease
Vasospasm- Prinzmetal Angina
Increased oxygen demands of the myocardium- aortic stenosis, hypertrophic cardiomyopathy, HTN

Question 4

What percentage stenosis usually leads to angina?

Answer 4

> 70%

Question 5

What is the difference betweens stable and unstable angina?

Answer 5

Stable Angina- Pain experienced on exertion

Unstable Angina- Pain experienced at rest, not eased by GTN spray

Question 6

Why might aortic stenosis lead to angina pain?

Answer 6

Increased resistance to flow during systole due to the stenosed vessel. Myocardium hypertrophies to overcome this increased resistance which leads to increased oxygen demands and demand ischaemia if blood supply inadequate.

Question 7

Why might angina from emotional stress persist for longer?

Answer 7

Due to circulating adrenaline which increase HR and so the oxygen demands of the myocardium increase

Question 8

What triggers unstable angina?

Answer 8

Thrombosis- atherosclerotic plaque rupture which leads to clot formation overlying it

Question 9

What is prinzmetal angina?

Answer 9

Angina that occurs due to vasospasm of the coronary arteries

Question 10

What drug can cause coronary artery vasospasm?

Answer 10

Cocaine

Question 11

What ischaemic changes might be seen on an ECG in someone with angina on exertion?

Answer 11

ST depression
T wave inversion

Note- this these are the same changes seen in NSTEMI and Unstable angina, or the ECG may be normal

Question 12

What is used to treat angina?

Answer 12

Glyceryl trinitrate- sublingual preparation

This is taken when episodes of discomfort come on and rapidly reduces the pain by causes vasodilation

Question 13

What is a contra-indication to GTN?

Answer 13

Hypotension

Question 14

What are some triggers to angina?

Answer 14

Exertion
Emotional Stress
Exposure to cold
Eating a large meal

Question 15

What are some adverse effects of GTN?

Answer 15

Flushing
Headaches
Dizziness

Question 16

What important advice should be given to angina patients about managing their pain?

Answer 16

If after a second dose of GTN (wait 5 minutes after 1st and 2nd) they should call 999

Or earlier if the pain is intensifying or the patient is unwell

Likely ACS picture

Question 17

What medications should be given to patients with angina?

Answer 17

GTN

Beta blocker or a calcium channel blocker to reduce the symptoms by decreasing HR and myocardial oxygen demands

Question 18

What is the gold standard investigation to assess for coronary artery narrowing?

Answer 18

CT Coronary Angiogram- this is the main investigation if no prior history of CVD

Question 19

What investigations would you request for a patient with angina pain?

Answer 19

Bloods-
FBC- Anaemia can cause low oxygen supply to myocardium
U and Es- Important to know prior to starting medication, especially ACEi or ARBs
LFTs- Important to know before starting a statin
Lipid Profile- Modifiable risk factors
TFTs- Hyperthyroidism can cause tachycardia
HBA1c and Fasting Glucose- risk factor for atherosclerotic disease

ECG- Ischaemic changes
ECHO- If indicated to rule out structural issues and valve function
CXR- rule out possible respiratory pathology, cardiomegaly

Question 20

What would you want to assess on examination of a patient with angina?

Answer 20

Blood pressure- increased afterload
Heart sounds- Aortic stenosis?
Signs of anaemia- low oxygen capacity of blood
Signs of heart failure- JVP, Lung Bases, Pitting oedema
Quick resp assessment to rule out resp causes of chest pain

Question 21

How can the RAMP mnemonic help to remember the management of angina?

Answer 21

Refer to cardiology
Advice when to call an ambulance- if two doses of GTN fail to improve the pain, or intense/worsening picture or unwell
Medical treatment
Procedural or surgical investigations

Question 22

What are the three aims of the medical management?

Answer 22

Immediate relief- GTN
Long term relief- Beta blockers, calcium channel blockers
Secondary prevention- Statins, Glycaemic control, ACEi, Aspirin (reduce risk of MI)

Question 23

Summarise the three aims of medical management of angina?

Answer 23

Immediate relief
Long term relief
Secondary prevention

Question 24

What is used for immediate symptomatic relief of angina pain?

Answer 24

GTN

Question 25

What is used for long term symptomatic relief?

Answer 25

Beta blocker- e.g. Bisoprolol 5mg OD Calcium channel blocker- Amlodipine 5mg OD May be combined

Question 26

What is a long acting nitrate?

Answer 26

Isosorbide mononitrate

Question 27

What surgical intervention may be considered?

Answer 27

PCI or coronary angioplasty

Question 28

Who is offered surgical interventions for angina?

Answer 28

Extensive or proximal disease on CT angiography | Or failure to control symptoms with optimal medical therapy

Question 29

Outline roughly how PCI is performed

Answer 29

Access via brachial or femoral artery Directed to coronary arteries and diseased vessel Ballon used to dilate the artery Stent put in place to keep lumen patent

Question 30

What are stents lined with to prevent luminal narrowing due to cell proliferation?

Answer 30

Chemotherapy agents/anti-proliferative agents

Question 31

Where is the graft vein often taken for CABG?

Answer 31

Great saphenous vein

Question 32

If you are examining a patient with suspected CVD where should you look for scars?

Answer 32

Brachial artery at the cubital fossa Femoral Artery- Mid inguinal point Midline sternotomy scar Distribution of the saphenous veins to check for vein harvest

Question 33

What should be given for secondary prevention in angina patients?

Answer 33

ACEi Statins Aspirin Note- people with PVD should already be taking clopidogrel and they should continue on this

Question 34

What should beta blockers never be combined with?

Answer 34

Verapamil or other non-DHPs calcium channel blockers e.g. Diltiazem but this is less cardioselective Also termed rate limiting calcium channel blockers and they should not be prescribed with a beta blocker as they can cause severe bradycardia and heart failure

Question 35

After stenting what should the patients stay on for around 12 months?

Answer 35

Dual platelets | Aspirin and Clopidogrel/Ticagrelor

Question 36

When should patients with angina be referred to cardiology?

Answer 36

Failure to control symptoms despite maximal first line medical therapy Ischaemic changes on ECG Note if any features of unstable angina this requires an urgent admission

Question 37

What are some 2nd line medications that can be offered to patients for long term symptoms relief?

Answer 37

Long acting nitrate Ivabradine Nicoradil Ranolazine (Likely given by specialist)