Chronic Chest Pain

Question 1

Chronic Angina is?

Answer 1

Symptom caused by fixed coronary stenosis in the arteries from atherosclerosis of coronary arteries.

Question 2

Patients symptoms at rest vs patients symptoms during physical activity

Answer 2

Rest: Blood supply to heart sufficient, patient is symptom free.

Physical activity: as Cardiac work and demand increases, partially occluded coronary vessel prevents this demand from being meet > ischaemic cardiac muscle and chest pain.

Back to rest: rebalance of flow, blood goes away

Question 3

Is treating chronic angina a medical emergency

Answer 3

No, it is more of a long-standing issue that can be treated. The issue is getting the patient to take their treatment

Question 4

Classical signs of angina

Answer 4

Age
Hypertension
smoke
diabetes
previous heart issues
Nausea, sweating
Pain/tightness/heaviness during movement, eases at rest.
Does the pain go to neck/L arm?

Question 5

Investigations you can do to diagnose

Answer 5

• Exercise-test with ECG to show ischaemia as HR inc
• Exercise echo
• CT scan of coronary arteries
• angiograms

Question 6

Examination you can do to diagnose angina

Answer 6

• Bp
• Weight
• Murmurs (stenosis)

Question 7

Angina Management

Answer 7

Pharmacological: reduce symptoms and/or CVS risk

Interventional: surgery, stent

Question 8

Pharmacological Treatments that reduce symptoms

Answer 8

• Beta-blockers (decrease energy and cardiac work)
• Nitrates (VD)
• Calcium channel blockers (VD)

Question 9

Pharmacological Treatments that reduce CVS risk

Answer 9

• Anti-platelets (aspirin)
• Lipid Lowering (statins)

More about long term outcome

Question 10

Typical drug list for a patient with chronic angina

Answer 10

1) Beta-blocker; metoprolol
2) Calcium channel blocker
3) isosorbide mononitrate
4) GTN spray ‘as required’
5) aspirin
6) statin

This is an issue, as patient compliance is low due to a quite hefty list of drugs they are required to take daily.

Question 11

Drug management

Answer 11

• initiate drug
• Titrate dose (start w low dose)
• Review patient; symptoms resolution, side effects

Long term followup required

Question 12

Beta-blockers

Answer 12

-Reduce cardiac work: decrease HR and c.work (aim HR: 60-70bpm)
decrease ischaemic burden

• Reduce BP
• Improve prognosis
• FIRST LINE THERAPY to reduce angina symptoms

Question 13

Calcium Channel Blockers

Answer 13

-Block voltage-operated L-type Ca channels; in cardiac and SM
Vascular smooth muscle: decreases arterial SM tone, vascular peripheral resistance, BP

Cardiac cells: decrease contractility, sinus node rate and AV node transmission

-Some selectivity between tissues

Question 14

Calcium channel blockers for resistance vessels

Answer 14

Dihydropyridine

• ) flushing, headache, oedema

Question 15

Calcium channel blockers for cardiac tissue

Answer 15

Phenylalkylamine

• )Heart block, negative inotrope, constipation

Question 16

Nitrates

Answer 16

-Vasodilators, can be used everyday (chronic) or for acute required use (can be done because they are so lipophilic! straight into circulation!)

Question 17

Nicorandil

Answer 17

1) Nitrate-like effect
2) K+ ATP channel opener: hyperpolarises cell and inactivates VC

• symptom relief
• Predictable side effects (headaches)

Question 18

Lipid-lowering drugs: Statins

Primary and secondary prevention

Answer 18

Primary Prevention: treat if 10 year CVS >30%

Secondary Prevention: coronary artery disease (angina)**, cerebrovascular disease, peripheral vascular disease

Question 19

Frequently used statins in NZ

Answer 19

simvastatin

atorvastatin
Heaps of evidence of effect.
there are some others that are less frequently used due to being less effective

Question 20

Statins: mechanism of action

Answer 20

Synthasizing cholesterol (in hepatocytes) is v important. Acetyl CoA to cholesterol

Statins inhibit enzyme ‘HMG CoA reductase’, stoping the step in the pathway

HMG Coa –X—> Mevalonate

Hepatocytes, respond to this by expressing lots of LDL receptors, effectively ‘mopping’ up the circulating LDL to make/use sufficient cholesterol

LDL levels lower

Question 21

Concern with using statins

Answer 21

lots of potentially drug interactions: simvastatins is metabolised by cytochrome P450

Side Effects:

• Myalgias (aches and pains), reduce dose?
• Myositis; stop if CK x10
• Rhabdomyolysis; overwhelming inflamm/destruction, releases myoglobin
• Deranged LFTs; stop if ALT x3

Teratogenic: shouldn’t be given in pregnancy