Stable angina

Question 1

Name 5 risk factors for Coronary artery disease

Answer 1

Non-modifiable:

• Increasing age
• Male
• Genetics
• FHx
• Ethnicity

Modifiable:

• Smoking
• Hyperlipidaemia
• HTN
• Obesity and sedentary lifestyle
• Excessive alcohol
• Diabetes mellitus
• Gout

Question 2

What tool is used to identify cardiovascular risk? When should treatment be started to prevent CV disease?

Answer 2

QRISK2 risk assessment

Atorvastatin 20mg if 10yr-CV risk 10%+

Atorvastatin 80mg if established CV disease

Question 3

Suggest five preventative measures for cardiovascular disease

Answer 3

Lifestyle:

• Low fat diet (<30% total kcal)
• Low cholesterol intake (<300mg/d)
• 5 fruit/veg a day
• Exercise at least 150 min (moderate) or 75 min (intense)
• BMI <25
• Smoking cessation

Medical:

• HTN control
• DM control
• Atorvastatin if 10yr-CV risk 10%+

Question 4

Define Angina pectoris

Answer 4

Chest pain due to coronary artery disease that occurs on physical exertion or stress and is relieved by rest.

Question 5

Describe the characteristics of Classical angina

Answer 5

• Chest pain is typically heavy, tight, or griping
• Central/retrosternal
• May radiate to jaw and/or arms

Question 6

Outline the functional classification of angina

Answer 6

Class I: No angina with ordinary activity. Angina with strenuous activity.

Class II: Angina with ordinary activity, with mild limitation of activities.

Class III: Angina with low levels of activity, with marked restriction of activities.

Class IV: Angina at rest or with any level of exercise.

Question 7

Define unstable angina

Answer 7

• Angina of recent onset (<24h) or;
• Deterioration in previous stable angina
• Symptoms occurring at rest.

Question 8

Suggest three initial laboratory investigations for stable angina

Answer 8

• FBC: exclude anaemia
• TFT: hyperthyroid increases work of heart; hypothyroid associated with hypercholesterol
• Fasting glucose, HbA1c: co-morbid DM
• Fasting lipid
• U+E
• LFTs: statins can cause abnormal AST/ALT
• Troponin if unstable

Question 9

Suggest two bedside investigations used in stable angina?

Answer 9

• 12-lead ECG: exclude ACS, pathological Q waves, LVH, LBBB
• ECHO: Regional wall abnormalities, LV ejection fraction, diastolic function
• Ambulatory ECG (Holter monitoring): Paroxysmal AF, Prinzmetal (vasospastic) angina

Question 10

What radiological investigation is useful in stable angina?

Answer 10

CXR: Atypical angina, pulmonary disease, heart failure

CT coronary angiography

Question 11

Outline the initial management of stable angina

Answer 11

• Reassurance (mortality <2% annually)
• Lifestyle modifications:
  
  • Smoking cessation, diet, exercise
• Short-acting nitrate
• Secondary prevention:
  
  • Aspirin 75mg daily
  • ACEi if diabetic
  • Atorvastatin
  • Hypertensive treatment

Question 12

What side effects may occur with short-acting nitrates? What advice should be given regarding its use?

Answer 12

Flushing, headaches, and light-headedness Advise to repeat dose after 5 minutes if pain remains. Call an emergency ambulance if pain has not gone 5 minutes after taking a second dose.

Question 13

Outline what anti-anginal drug treatment is available

Answer 13

Beta blocker or CCB as first-line treatment for angina If one not tolerated/contraindicated, consider: Switching to the other option Using a combination of the two If both not tolerated/contraindicated, consider one of the following: Long-acting nitrate Ivabradine: Inhibits funny current in SA node Nicorandil: Peripheral and coronary vasodilatation Ranolazine: Inhibits late Na channels in cardiac cells

Question 14

What is the indication for invasive intervention in stable angina? What surgical options exist?

Answer 14

Revascularisation is indicated if symptoms are not satisfactorily controlled with optimal medical treatment (two anti-anginal medications). Percutaneous coronary intervention (PCI): Used if single vessel disease, multi-vessel disease <65yr, with suitable anatomy. Coronary artery bypass graft (CABG): Used if unsuitable anatomy for PCI, multi-vessel disease >65yr, diabetes.

Question 15

Name 3 vessels used in coronary artery bypass

Answer 15

Left internal mammary artery: Best long-term result Radial artery: Must perform Allen test Long saphenous vein: Ease to harvest *Arterial grafts are better and more durable than veins

Question 16

What diagnosis is given to patients with normal coronary arteries and continuing anginal symptoms?

Answer 16

Cardiac syndrome X/Microvascular angina Only continue drug treatment if it improves symptoms