Angina: chest pain (or constricting discomfort) caused by an insufficient blood supply to the heart muscle
Causes
Angina is usually caused by coronary artery disease.
Less commonly, angina is caused by valve disease (for example aortic stenosis), hypertrophic obstructive cardiomyopathy, or hypertensive heart disease.
Stable angina usually occurs predictably with physical exertion or emotional stress, and is relieved within minutes of rest, or with a dose of sublingual glyceryl trinitrate.
Unstable angina is new (usually within 24 hours) onset angina, or abrupt deterioration in previously stable angina, often occurring at rest. Unstable angina usually requires immediate admission, or referral to hospital.
Management
smoking cessation
A cardioprotective diet should be encouraged.
Advice and support should be offered to help achieve and maintain a healthy weight if people are overweight or obese.
An increase in physical activity levels should be encouraged within the limits set by their symptoms.
Limitation of alcohol consumption to within recommended levels should be encouraged.
Treatment
Sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms of angina and for use before performing activities known to cause symptoms of angina.
A beta-blocker or a calcium-channel blocker as first-line regular treatment to reduce the symptoms of stable angina.
Second-line treatment such as a long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine.
If symptom control is poor on the maximum licensed, or highest tolerated dose of one drug, another drug from a different class should be switched to, or added in.
If symptom control is poor on the maximum licensed, or tolerated doses of two drugs, referral to a cardiologist (for assessment for revascularization) should be arranged.
Starting a third anti-anginal drug should be considered whilst waiting for specialist assessment.
Secondary preventative drug treatment
Antiplatelet treatment should be considered in all people with stable angina. For most people this will be low-dose aspirin (75 mg daily).
An angiotensin-converting enzyme (ACE) inhibitor should be prescribed for people with coexisting hypertension, heart failure, asymptomatic left ventricular dysfunction, chronic kidney disease, or previous myocardial infarction in line with current guidance, unless this is contraindicated or not tolerated. Treatment with an ACE inhibitor should be considered for people with stable angina and diabetes mellitus.
A statin should be offered in line with NICE guidance on lipid modification.
Treatment for hypertension should be offered in line with NICE guidance on hypertension.
Hospital admission
Pain at rest (which may occur at night).
Pain on minimal exertion.
Angina that seems to be progressing rapidly despite increasing medical treatment.
Assessment
Physical assessment
general appearance
abdomen tenderness/distension
chest examination-palpate for tenderness, assess pain, signs of infection, resp rate, and pulse oximetry
neck - tenderness/stiffness
heart sounds,BP in both arms, JVP, pulse (rate and rhythm), carotid pulse, ankle oedema
skin- rashes or bruising
legs and calves- swelling/tenderness
temperature- pyrexia over 38.5oc, infection, pericarditis, pancreatitis
Classify symptoms
typical
atypical
Precipitated by physical exertion.
Constricting discomfort in the front of the chest, in the neck, shoulders, jaw, or arms.
Relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
two of the above
GI discomfort and/or breathlessness and/or nausea
Risk factors
Stable angina
Unstable angina
increasing age, male, presence of CVS risk factors, Hx of CAD
Pain that is persistent/continuous, unrelated to activity, brought on by breathing, associated with dizziness, palpation's, difficulty in swallowing
Differentials
MSK- rib fracture, spinal disorders, costochondritis
Pulmonary- PE, pneumothorax, CAP, asthma
GI- pancreatitis, oesophageal rupture, GORD, PU disease, cholecystitis
Cardiac- ACS, CCF,Aneurysm
Other-psychogenic, herpes zoster, coxsachie B virus, precordial catch
Referral
Previous myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty and development of angina.
ECG (electrocardiographic) evidence of previous myocardial infarction or other significant abnormality.
Newly diagnosed atrial fibrillation and angina.
Heart failure and angina.
An ejection systolic murmur suggesting aortic stenosis.
Any suggestion of hypertrophic cardiomyopathy (for example by family history, physical examination, or ECG).
doubt about diagnosis
Strong Fhx
12 lead ecg
ECHO