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Angina pectoris (Types/variants (Decubitus Lying flat, Nocturnal At…
Angina pectoris
Types/variants
Decubitus
Lying flat
Nocturnal
At night
Stable
Angina pectoris
Prinzmetals/variant
Spasm of arteries
Cardiac syndrome X
?Abnormal function of microcirculation
Unstable
Part of the ACS
Clinical
presentation
Chest pain
Radiation
Arms, teeth, jaw
Associated symptoms
Breathlessness, nausea, syncope, sweaty
Character
Crushing/tightness/heavy
Timing
As long as exertion lasts
Onset
Sudden
Exacerbating/relieving
Exacerbating: effort, cold, emotion
Relieving: rest, GTN (<5min)
Site
Central, retrosternal
Breathlessness
Syncope
Nausea
Sweating
Aetiology
Metabolic
Anaemia
Autoimmune
Small vessel arteritis
Vascular
Atheroma (commonest)
Valve disease - AS
Arrhythmias
Hypertrophic cardiomyopathy
Idiopathic
CA spasm (Prinzmetal's)
Cardiac syndrome X
Diagnosis
Examination
Often nil; pallor (anaemia), murmurs (AS), arrhythmias
Investigations
Bedisde
Obs (sats, RR, HR, BP, temp)
ECG (arrhythmia, MI)
BM (DM)
Bloods
FBC (anaemia). U+Es, LFTs
cardiac enzymes, glucose, lipids
Imaging
Functional imaging (e.g. stress ECHO) if atypical pain
Exercise/pharma ECG testing (if atypical pain)
Angiography (if uncertain diagnosis)
History
DH
Medications, allergies
FH
Cardio disorder
PMH
Cardiac disease, anaemia,
thyroid disorder
SH
Stress, smoking,
alcohol, diet, exercise
PC/HPC
Pain (SOCRATES), breathlessness,
palpitations, syncope, nausea
Management
Medical
Secondary
prevention
Antiplatelet
Indication: all patients
E.g. aspirin 1L, clopidogrel 2L
MOA: aspirin inhibit COX, reducing TX and platelet aggregation;
clopidogrel ADP-R antagonist, reducing platelet aggregation
SE: gastric ulcers/irritation/bleeding
Lipid-lowering agent
Indication: all patients
E.g. statin 1L (atorva/simvastatin), fibrate 2L (bezafibrate, ezetimibe)
MOA: inhibit cholesterol production
SE: myalgia, myositis, abdominal pain, deranged LFTs
ACEi
Indication: all patients
E.g. ramipril
MOA: inhibit Ang II formation, causes vasodilatation
SEs: cough, hyper-K, renal failure
CI: pregnancy, bilateral RAS
Symptom
relief
Long-acting CCBs
Indication:
E.g. dihydropyridines (amlodipine), non-dihydropyridines (diltiazeim)
MOA: dihydropyridines dilate peripheral and coronary arteries; non-dihydrophyridines also reduce SAN/AVN conduction
CI: heart block
SE: postural hypotension, headache, ankle oedema
Nitrates
E.g. GTN spray/tablets/patches/pills
MOA: reduce venous pressure and dilate coronary arteries
SE: headaches, hypotension
B-blockers
Indication: 1L
E.g. atenolol, metoprolol
MOA: reduce HR and force of
contraction, reducing O2 demand
CI: asthma, COPD, heart block
SEs: bronchospasm, headache, ED, tiredness
K+ channel activator
Indication: add-on therapy
E.g. nicorandil
MOA: dilates arteries and veins
If current inhibitors
Indication: add-on therapy
E.g. ivabrandine
MOA: inhibits SAN If currents, reducing HR
Na channel inhibitor
Indication: add-on therapy
MOA: interacts with Na channels to
improve exercise tolerance
SE: prolonged QT
Surgical
CABG
Indication: persistent/worsening
MOA: replacement of CA with graft
(internal mammary artery or saphenous veins)
PCI
Indication: persistent/worsening
MOA: angioplasty +/- stent to widen CA
Conservative
Information, advice and support
Referral if diagnostic uncertainty, sudden onset, recurrent/uncontrolled/unstable
Lifestyle (smoking, alcohol, weight loss, exercise, diet)
Manage HTN, DM, etc.
Epidemiology
Common
Elderly
Definition
Chest pain from the heart due to
myocardial ischemia