Angina

• Stable angina lector is is mainly caused by coronary artery disease. Can also be caused by valvular disease and hypertrophic cardiomyopathy.
• Stable angina presents with central chest pain that is usually described as tightness/heaviness. The pain can radiate to the arms and jaw. The chest pain is brought on by exertion. The chest pain is relieved by rest or GTN spray. The pain usually lasts less than 20 minutes.
• Angina chest pain can be accompanied by dyspnoea, nausea, sweatiness and faintness
• Risk factors for stable angina include: smoking, hypertension, diabetes, dyslipidemia, obesity and a family history of coronary artery disease.
• The diagnosis of stable angina is mainly a clinical one. An ECG may show ST depression and T wave inversions. Blood tests are done to exclude precipitating factors. An echo or coronary CT angioplasty can be considered.
• Management of stable angina includes life style changes such as smoking cessation. GTN spray is used PRN for the relief of chest pain. Secondary prevention of CVD is needed. This includes aspirin and statins, an ACE inhibitor can be considered. Anti anginal drugs are beta blockers and calcium channel blockers. Beta blockers are the first line treatment.
• Revascularisation with CABG or PCI can be considered in angina patients with evidence of extensive ischemia or poor symptom control despite maximal drug therapy.
• The use of asprin in angina patients blocks platelet aggregation and therefore decreases the chance of progression to unstable angina
• GTN spray is glyceryl trinitrate spray. It converts to NO in the body which causes the re-uptake of calcium into the sarcoplasmic reticulum. this causes the relaxation of smooth muscle, restoring blood flow to the heart muscles.
• Beta blockers are the first line treatment for stable angina. They block the beta-adrenoreceptors to antagonise the sympathetic nervous system. This decreases heart rate and reduces peripheral vasoconstriction. Overall this decreases myocardial oxygen demand.
• Bisoprolol and antenol are examples of beta blockers. Side effects include bradycardia, cold peripheries and depression.
• Immediate symptomatic relief is with sublingual glyceryl trinitrate (GTN) in the form of a spray or tablets. GTN causes vasodilation, improving blood flow to the heart muscle (myocardium). Patients are advised to:

  • Take the GTN when the symptoms start
  • Take a second dose after 5 minutes if the symptoms remain
  • Call an ambulance if the symptoms remain 5 minutes after the second dose
• Key side effects of GTN are headaches and dizziness caused by vasodilation.
• Surgical procedures are generally offered to patients with more severe disease and where medical treatments do not control symptoms. There are two options:

  • Percutaneous coronary intervention (PCI)
  • Coronary artery bypass graft (CABG)
• Lab investigations:

  • ECG (a normal ECG does not exclude stable angina)
  • FBC (anaemia)
  • U&Es (required before starting an ACE inhibitor and other medications)
  • LFTs (required before starting statins)
  • Lipid profile
  • Thyroid function tests (hypothyroidism or hyperthyroidism)
  • HbA1C and fasting glucose (diabetes)
• Other investigations:

  • Cardiac stress testing
  • CT coronary angiography
  • Invasive coronary angiography - gold standard