Chronic - Stable angina

Question 1

Describe the features of typical angina

Answer 1

ALL 3

• Constricting discomfort in the chest, neck, shoulders or jaw
• Precipitated by exercise
• Relieved by rest or GTN within 5 minutes

Question 2

Is stable angina an acute coronary syndrome?

Answer 2

no

Question 3

Stable angina is typically predictable and reproducible. Is each episode of chest pain brought on by the same type and amount of exercise?

Answer 3

Not necessarily - this can vary from one occasion to another

In particular, the chest pain may come on earlier when exercising after a meal or when in a cold environment.

Question 4

Does stable angina undergo rapid worsening over time?

Answer 4

no - that is why it is called ‘stable’ angina

Question 5

What are the main aims of treatment for stable angina?

Answer 5

• PRN symptom relief
• anti-anginal medication
• secondary prevention of CVD disease

Question 6

What is included in the first-line management of stable angina?

Answer 6

• PRN symptom relief - GTN spray
• Anti-anginal medication - Bisoprolol or Verapamil
• Secondary prevention of CVS disease - lifestyle advice, control HTN, ACEi if diabetes, aspirin 75mg OD, atorvastatin 80mg

Question 7

What would you look for on examination if you think the patient may have coronary artery disease?

Answer 7

• Signs of CVS risk factors (BMI, xanthoma, xanthelasma),
• Signs of damage (heart sounds, signs of heart failure)
• Signs of procedures: check for a midline sternotomy scar (previous CABG), scars around the brachial and femoral arteries (previous PCI) and along the inner calves (saphenous vein harvesting scar)

Question 8

What specific questions would you ask if you are suspecting coronary artery disease?

Answer 8

SQUITARS, associated symptoms e.g. breathlessness

PMH - previous MI/stroke

SH - smoking, alcohol, exercise, diet

FH - MI/stroke/PVD, if yes - what age?

Question 9

What is atypical angina?

Answer 9

2 of:

• Constricting discomfort in the chest, neck, shoulders or jaw
• Precipitated by exercise
• Relieved by rest or GTN within 5 minutes

Question 10

What is non-anginal chest pain?

Answer 10

1 or 0 of:

• Constricting discomfort in the chest, neck, shoulders or jaw
• Precipitated by exercise
• Relieved by rest or GTN within 5 minutes

Question 11

What should be done if the chest pain is classed as ‘non-anginal’?

Answer 11

• Consider other causes of chest pain other than angina
• Only consider CXR if other diagnoses e.g. lung cancer are suspected
• Do not offer diagnostic testing to people with non-angina chest pain on clinical assessment unless there are resting ECG changes (ST or Q waves)

Question 12

What factors can trigger angina?

Answer 12

• Exertion
• Emotional stress
• Exposure to cold
• Eating a large mea

Question 13

Should treatment for stable angina be initiated without the results of definitive investigations?

Answer 13

yes - Follow the recommendations on managing stable angina while waiting for the results of investigations if symptoms are typical of stable angina.

Question 14

What advice would you give regarding the use of a GTN spray?

Answer 14

Indication: Preventing and treating episodes of angina

• Immediately before any planned exercise or exertion

Instructions: If they experience chest pain they should:

• Stop what they are doing and rest
• Use GTN spray as instructed
• Take a second dose after 5 mins if the pain has not eased
• Call 999 if pain has not eased 5 mins after the second dose, or earlier if the pain is intensifying

Side effects:

• flushing, headache, light-headedness (sit down or find something to hold on if feeling light-headed)

Question 15

What is the 1st line anti-anginal medication?

Answer 15

beta-blocker (bisoprolol)/calcium-channel blocker (amlodipine)

Question 16

1st line anti-anginal treatment of stable angina is either a beta blocker or calcium channel blocker. What should be done if this does not control symptoms?

Answer 16

Referral to cardiologist for specialist treatment with monotherapy of one of the following:

• Long-acting nitrate – isosorbide mononitrate
• Nicorandil
• Ivabradine
• Ranolazine

Question 17

What drugs are given for secondary prevention in stable angina?

Answer 17

Secondary prevention treatment – to prevent CVS events such as MI/stroke (4As)

Anti-platelet treatment taking into account bleeding risk and comorbidities – aspirin

ACEi if stable angina and diabetes mellitus

Statin – atorvastatin

Anti-hypertensive treatment if appropriate

Question 18

What safety netting advice would you give someone with stable angina?

Answer 18

Call 999 if:

• pain has not eased 5 mins after the second dose of GTN, or earlier if the pain is intensifying after
• Pain at rest
• Pain on minimal exertion

Question 19

Most patients with stable angina are initially successfully managed by their GP. When would a patient with stable angina be referred to a cardiologist?

Answer 19

Basically pre-existing or co-existant cardiac disease complicating the angina -

• Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina.
• ECG (electrocardiographic) evidence of previous myocardial infarction or other significant abnormality.
• Newly diagnosed atrial fibrillation and angina.
• Heart failure and angina.
• An ejection systolic murmur suggesting aortic stenosis.
• Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG).

Question 20

Which initial investigations would be carried out on a patient presenting with a history of chest pain?

Answer 20

Resting 12-lead ECG

• Do not rule out a diagnosis of stable angina on the basis of a normal resting 12-lead ECG
• May indicate ischaemia or previous infarction:
  
  • Pathological Q waves
  • LBBB
  • ST-segment and T wave abnormalities

Bloods - troponin T/I and creatine kinase (if current chest pain), FBC (anaemia), U&E’s (ACEi), LFTs (statin), lipid profile (statin), TFTs, HBA1c (diabetes)

Question 21

Which diagnostic investigations are carried out on patients presenting with symptoms of typical or atypical angina?

Answer 21

CTCA (first line) – inject contrast and taking CT images timed with the heart beat to give a detailed view of the coronary arteries, highlighting any narrowing

Question 22

Should patients presenting with non-anginal chest pain be referred for CTCA?

Answer 22

Indicated in non-angina chest pain if 12-lead resting ECG shows ST segment/T wave changes or Q waves

Question 23

When is non-invasive functional testing carried out?

Answer 23

CTCA has shown coronary artery disease of uncertain functional significance or is on-diagnostic

Question 24

What is non-invasive functional testing?

Answer 24

• Myocardial Perfusion Scan with SPECT
• Stress echocardiography
• First-pass contrast-enhanced magnetic resonance perfusion
• MRI for stress-induced wall motion abnormalities

Question 25

When is invasive angiography indicated for the investigation of stable angina?

Answer 25

Results of non-invasive functional imaging are inconclusive

Question 26

What are the 1st, 2nd and 3rd line investigations for stable angina?

Answer 26

1. CT coronary angiogram 2. Non-invasive functional testing 3. Invasive coronary angiography

Question 27

What is PCI?

Answer 27

Involves putting a catheter into the patient’s brachial or femoral artery, feeding that up the coronary arteries under xray guidance and injecting contrast so that the coronary arteries and any areas of stenosis are highlighted on the xray images. This can then be treated with balloon dilatation followed by insertion of a stent

Question 28

What is CABG and how does it compare to PCI?

Answer 28

* Involves opening the chest along the sternum (midline sternotomy scar), taking a graft vein from the patient’s leg (usually the great saphenous vein) and sewing it on to the affected coronary artery to bypass the stenosis * Recovery is slower and complication rate is higher than PCI

Question 29

When would PCI/CABG be considered in patients with stable angina?

Answer 29

* Symptoms NOT satisfactorily controlled with optimal medical treatment * Investigations shows proximal or extensive coronary artery disease

Question 30

As a GP seeing a patient with first presentation suspected stable angina, you would do the initial investigations (12-lead ECG and bloods). Then, how would you confirm the diagnosis of stable angina?

Answer 30

If the person has typical or atypical anginal pain, refer them to a specialist chest pain service to confirm, or exclude the diagnosis of stable angina. Include a description of the features of anginal chest pain in all requests for diagnostic investigations - CTCA is 1st line.