Stable Angina

Question 1

What is stable angina?

Answer 1

Pain, pressure or sense of heaviness in the chest beneath sternum.
Predictable - bought on by exertion.

Question 2

What does NICE indicae as the 3 characteristics of angina pain?

Answer 2

• constricting discomfot in chest, neck, shoulders, jaw and/or arms.
• precipitated by physical exertion.
• relieved by GTN in 5 mins.

Question 3

What if you have 2 of the NICE characteristics of anginal pain?

Answer 3

Atypical angina

Question 4

What is you have 3 characteristics of NICE anginal pain?

Answer 4

Typical angina

Question 5

What other tests should be done to rule in angina?

Answer 5

• 12-lead ECG

Question 6

What 3 factors make a diagnosis of angina more likely?

Answer 6

• increasing age
• male gender
• CV risk factors - smoking, HTN, CAD etc.

Question 7

What 3 tests should be done if patients has suspected angina and why?

Answer 7

• Hb levels - anaemia can exacerbate chest pain.
• Thyroid function - can exacerbate CAD
• Fasting BG - diabetics have worse prognosis - need more aggressive Tx.

Question 8

What 5 other conditions can be associated with chest pain?

Answer 8

MI/ACS
GORD
Bone/muscle problems
Lung conditions 
Anxiety

Question 9

What is the strongest predictor of long-term survival for angina patients with IHD?

Answer 9

LVEF

Question 10

What 2 factors are for acute treatment of angina?

Answer 10

Rest

GTN spray

Question 11

What 4 main treatments are available for long-term mgmt of angina?

Answer 11

B-blockers,
CCBs
Nitrates
Nicorandil

Question 12

What 2 novel agents are available for angina?

Answer 12

Ivabradine

Ranolazine

Question 13

What other 2 medications should patients with angina be on?

Answer 13

Anti-platelet

Statin

Question 14

Explain why GTN is given sublingually?

Answer 14

Bypass hepatic metabolism and causes venous dilatation at lower doses than required for systemic absorption.

Question 15

What is important to note about GTN tabs?

Answer 15

Only last 8 weeks once opened.

Must be given in original glass container.

Question 16

What are GTN patches used for?

Answer 16

Provide constant GTN over 24 hours

Question 17

For what 3 reasons are the GTN patches critised?

Answer 17

Expensive

Development of nitrate tolerance

Limited effect of lower dose patches.

Question 18

Why is the nitrate free window important and how long should it be?

Answer 18

To prevent development of tolerance.

Should be 10-12h.

Question 19

Can S/L GTN be given prophylactically?

Answer 19

Yes - can take before planned exertion.

Question 20

In an angina attack - how should GTN be used?

Answer 20

• use one spray under tongue and wait 5 mins.
• if pain unresolved use another dose and wait 5 minutes.
• if pain unresolved 5 mins after SECOND dose - call 999.

Question 21

Which drugs are severely C/I with GTN?

Answer 21

Vasodilators eg sildenafil - would cause massive hypotension.

Question 22

What are the first ling options for angina?

Answer 22

B-blocker

CCB

Question 23

MoA of B-blockers?

Answer 23

Inhibit B-adrenoceptorsto prevent sympathetic stimulation and lower HR, BP and myocardial contractility.

Question 24

MoA of CCBs in stable angina?

Answer 24

• Cause systemic vascular dilatation.
• reduce myocardial contractility.
• slow sinus and AVN conduction

Question 25

What is the difference between dihydropyridine and non-dihydropyridine CCBs?

Answer 25

N❤︎N-DHP - verapamil,diltiazem DHP - nifedipine, amlodipine, felodipine.

Question 26

Which combination of drugs should be avoided?

Answer 26

B-blockers + verapamil/diltiazem

Question 27

MoA nicorandil?

Answer 27

K-channel activator - increase efflux of K from cells = hyperpol = vasodilation.

Question 28

Is nicorandil licensed in the UK for stable angina?

Answer 28

No - commonly used as an"add-on" treatment.

Question 29

what is an important caution with nicorandil?

Answer 29

Can cause skin, mucosal and eye ulceration - ie risking GI ulcers.

Question 30

MoA ivabradine?

Answer 30

Selectively inhibits current of SAN - reduced HR - reduced oxygen demand.

Question 31

Ivabradine should one be started in patients with _____ rhythm and pulse __ bpm?

Answer 31

Sinus rhythm 70 bpm minimum

Question 32

Can ivabradine be combined with DHP CCB-s?

Answer 32

Yes

Question 33

Can ivabradine be combined with NON-DHP CCBs?

Answer 33

No - they will increase exposure of ivabradine.

Question 34

MoA ranolazine?

Answer 34

MoA largely unknown - does inhibit late sodium current in cardiac cells - reduced intracellular sodium and decreases calcium overload.

Question 35

What is important to remember about the different brand of diltiazem?

Answer 35

They are not always bioequivalent. Patient should remain on the same brand as far as possible. Any changes should be noted in terms of bioequivalence and explained to prescriber.

Question 36

What is thedifferent between XL/LA and SR/PR preparations of diltiazem?

Answer 36

XL/LA - once daily dose SR/PR - BD dosing.

Question 37

What is the interaction between diltiazem and simvastatin?

Answer 37

Diltiazem increases simvastatin exposure - reduce simvastatin dose to 20mg daily.

Question 38

When should s PCI or CABG be considered for angina?

Answer 38

When >2 drugs are needed for angina control.