Stable Angina

Question 1

What is angina?

Answer 1

Atherosclerosis affecting coronary arteries reducing blood flow to myocardium
I’m high demand there is insufficient blood flow to meet demand

Question 2

What is the difference between stable and unstable angina?

Answer 2

• Angina is “stable” when symptoms only come on with exertion and are always relieved by rest or glyceryl trinitrate (GTN).
• It is “unstable” when the symptoms appear randomly whilst at rest. Unstable angina is a type of acute coronary syndrome (ACS) and requires immediate management.

Question 3

What are the signs and symptoms of stable angina? (3)

Answer 3

• Constricting pain experienced in the chest +/- typical radiation to the arm/neck/jaw
• Precipitated by physical exertion
• Relieved by rest or GTN within 5 minutes

Question 4

What is cardiac stress testing?

Answer 4

○ involves assessing the patient’s heart function during exertion.
○ This can involve having the patient exercise (e.g., walking on a treadmill) or giving medication (e.g., dobutamine) to stress the heart.
○ The options for assessing cardiac function during stress testing are an ECG, echocardiogram, MRI or a myocardial perfusion scan (nuclear medicine scan).

Question 5

What is the gold standard investigation for stable angina?

Answer 5

Angiography

Question 6

What is a CT coronary angiography?

Answer 6

involves injecting contrast and taking CT images timed with the heart contractions to give a detailed view of the coronary arteries, highlighting the specific locations of any narrowing.

Question 7

What are the modifiable risk factors of stable angina? (5)

Answer 7

○ High cholesterol
○ Hypertension
○ Smoking
○ Diabetes
○ Obesity

Question 8

What are some non- modifiable risk factors of stable angina? (4)

Answer 8

○ Age
○ Family history
○ Male sex
○ Premature menopause

Question 9

What are the 5 principles of management for stable angina?

Answer 9

RAMPS
R – Refer to cardiology
A – Advise them about the diagnosis, management and when to call an ambulance
M – Medical treatment
P – Procedural or surgical interventions
S – Secondary prevention

Question 10

What is used for immediate symptomatic relief in stable angina?

Answer 10

GTN spray

Question 11

How does GTN spray work?

Answer 11

GTN causes vasodilation, improving blood flow to the heart muscle (myocardium).

Question 12

How should GTN spray be taken?

Answer 12

Always take when sitting down
§ Take the GTN when the symptoms start
§ Take a second dose after 5 minutes if the symptoms remain
§ Take a third dose after a further 5 minutes if the symptoms remain
§ Call an ambulance after a further 5 minutes if the symptoms remain

Question 13

What are the key side effects of GTN spray?

Answer 13

headaches and dizziness caused by vasodilation.

Question 14

What are the first line long term symptomatic relief of stable angina? (2)
Second line?
Third line? (4)

Answer 14

First line
○ Beta blocker (e.g., bisoprolol) OR
○ Calcium-channel blocker (avoid diltiazem or verapamil in heart failure with reduced ejection fraction etc as they slow the HR)

Second line
- use a combination of the 2 above

Third line
○ Long-acting nitrates (e.g., isosorbide mononitrate)
○ Ivabradine - lowers HR by acting on SAN
○ Nicorandil - nitrate-like action, K+ channel activator
○ Ranolazine - facilitates myocardial relaxation

Question 15

What is the action of ivabradine?

Answer 15

Lowers HR by acting on SAN

Question 16

What is the action of nicorandil?

Answer 16

Nitrate like action, K+ channel activator

Question 17

What is the action of ranolazine?

Answer 17

Facilitates myocardial relaxation

Question 18

What is the secondary prevention of CVD? (6)

Answer 18

• A – Aspirin 75mg once daily
• A - Another antiplatelet e.g. Clopidogrel/ticagrelor
• A – Atorvastatin 80mg once daily
• A – ACE inhibitor (if diabetes, hypertension, CKD or heart failure are also present)
• A – Already on a beta blocker for symptomatic relief
• A - Aldosterone antagonist (for those with clinical HF - eplerenone titrated to 50mg once daily)

Question 19

What is the dose of aspirin in secondary prevention of CVD?

Answer 19

75mg OD

Question 20

What is the dose of atorvostatin in secondary prevention of CVD?

Answer 20

80mg

Question 21

When should ACEi be used in secondary prevention of CVD?

Answer 21

If diabetes, HTN, CKD or HF are also present

Question 22

What is PCI?

Answer 22

• Percutaneous coronary intervention (PCI)
○ involves inserting a catheter into the patient’s brachial or femoral artery.
○ This is fed in, under x-ray guidance, through the arterial system to the coronary arteries.
○ Then a contrast is injected to visualise the coronary arteries and identify areas of stenosis on the x-ray images.
○ Areas of stenosis can be treated by dilating a balloon to widen the lumen (angioplasty) and inserting a stent to keep it open.
○ This can be referred to as coronary angioplasty and stenting.

Question 23

What is a CABG?

Answer 23

• Coronary artery bypass graft (CABG)
○ offered to patients with severe stenosis.
○ This involves opening the chest along the sternum, with a midline sternotomy incision.
○ A graft vessel is attached to the affected coronary artery, bypassing the stenotic area. The three main options for graft vessels are:
§ Saphenous vein (harvested from the inner leg)
§ Internal thoracic artery, also known as the internal mammary artery
§ Radial artery

Question 24

What scar is found after a CABG?

Answer 24

Midline sternotomy

Question 25

What are the benefits of pci over a CABG? (3)

Answer 25

• Faster recovery
• Lower rate of strokes as a complication
• Higher rate of requiring repeat revascularisation (further procedures)

Question 26

What are the lifestyle managements given in stable angina? (5)

Answer 26

• Diet: high in vegetables, fruit, and wholegrains. Limit saturated fat to <10% of total intake.
• Alcohol: limit alcohol to <100 g/week (12.5 units/week)
• Smoking: smoking cessation
• Exercise: 30-60 minutes of moderate activity. Even irregular exercise beneficial.
• Weight reduction: aim for healthy BMI (18-25 kg/m2)

Question 27

What scar is seen after PCI?

Answer 27

Brachial/femoral scars