Angina

1
Angina

By Lydia Jones
2
What is angina?

• Angina is the pain that accompanies periods of
  myocardial ischaemia
• The name is derived from the Greek 'agkone' which
  means strangling.
• Angina occurs when there is an increase in oxygen
  demand that cannot be met by supply. Some
  possible precipitants include exertion (e.g.
  climbing stairs), emotion, a large meal, cold
  windy weather.

3
Symptoms/features

• angina is typically a heavy or tight discomfort
  on or around the chest
• radiation pain generally radiates out from the
  chest, the commonest sites of radiation include
• neck and throat - causing a feeling of
  suffocation, strangulation, choking
• jaw - this may be interpreted as a problem with
  dentures or toothache
• down one or both arms generally felt down the
  inside of the arm, under the axilla to the inner
  two fingers. By contrast, muscular pain generally
  runs over the shoulder and down the outside of
  the arm
• other sites include the back, the abdomen and
  areas of previous injury.
• often angina is misinterpreted as indigestion.

4
Anginal syndromes

• Chronic stable angina
• Pain is provoked by physical exertion, especially
  after a meal, in cold weather or walking against
  the wind. The pain is often also aggravated by
  anger or excitement.
• The pain is relieved within 2-10 min by rest.
• Often angina will be precipitated by a
  predictable degree of exertion in a particular
  patient the threshold for pain varies widely
  between patient.
• The severity of the symptoms is not closely
  related to the extent of coronary artery disease,
  periods of ischaemia and myocardial infarction
  may be entirely painless.
• The pain is often more easily provoked in the
  morning.

5
Anginal syndromes

• Nocturnal angina
• Nocturnal angina wakes a patient from sleep and
  may be provoked by vivid dreams. Symptoms are
  commonest in the early hours of the morning when
  coronary artery tone is maximal.
• The patient often has critical coronary artery
  disease and hence usually suffers from exertional
  angina.
• Nocturnal angina may be associated with coronary
  artery spasm - Prinzmetal's angina.

6
Anginal syndromes

• Variant angina (Prinzmetal's)
• This is angina caused by focal spasm of
  angiographically normal coronary arteries. In ¾
  of patients there is also atherosclerotic
  coronary artery obstruction. The chest pain may
• occur at rest or wake the patient from sleep
• be accompanied by dyspnoea and/or palpitations
• be triggered by exertion there is variability in
  the workload required to precipitate pain
• The diagnosis of is made when the patient has
  angina in association with transient ST
  elevation, both of which resolve spontaneously,
  or with nitroglycerin.

7
Anginal syndromes

• Unstable angina
• Unstable angina is defined as recurrent episodes
  of angina on minimal effort or at rest. It may be
  the initial presentation of ischaemic heart
  disease, or it may represent the abrupt
  deterioration of a previously stable anginal
  syndrome.
• Unstable angina is provoked more easily and
  persists for longer than stable angina. It may
  fail to respond to therapy. Pain is often
  associated with reversible ST segment depression
  on the ECG.

8
Grading of Angina

• The Canadian Cardiovascular Society
  classification of angina recognises four levels
  of severity
• I
• ordinary physical activity does not cause angina
• strenuous physical activity provokes angina
• II
• some limitation of ordinary physical activity
• walking uphill or quickly up stairs provokes
  angina
• exercise tolerance 100-200 m before angina
• III
• marked limitation of ordinary physical activity
• climbing one flight of stairs provokes angina
• IV
• severely disable by angina
• angina on minimal exertion or at rest

9
Patient Case- Mrs Anne Gina

• After listening to her Hx you decide that she may
  have angina. What do you do in terms of
  examination?

10
Examination

• Full respiratory cardiovascular exam including
  looking for murmurs (aortic stenosis /carotid
  bruits- especially in diabetics)
• Anaemic?
• Check BMI
• Check BP

11
Patient Case- Mrs Anne Gina

• After examining her you decide that further Invx
  are warranted.
• How do you procede?

12
Investigation of angina in the community

• Blood tests
• random blood glucose
• cholesterol
• FBC
• electrolytes
• TFT
• Resting ECG- The ECG is usually normal between
  attacks. During an attack there may be a
  transient ST depression, symmetrical T wave
  inversion or tall, pointed upright T waves may
  appear.

13
Investigation of angina in the community

• A patient should be referred to a cardiologist if
  they have
• Aortic stenosis angina,
• Strong FHx
• there is diagnostic uncertainty
• Symptoms are not controlled with maximal dual
  therapy
• Where prognostic investigation is required, for
  example, post myocardial infarction
• Further investigaton includes

14
exercise ECG testing
15
Exercise ECG testing

• Contraindications- uncontrolled symptoms by max
  treatment, LBBB, cardiomyopathy, suspected/proven
  aortic stenosis, unable to run.
• The patient undergoes a standardized exercise
  protocol eg Bruce.
• The test is usually carried out with the
  assistance of cardiographic technicians, and they
  are generally very experienced at interpretation
  of ECG changes.

16
Patient Case- Mrs Anne Gina

• What management would you consider first?
• Is it purely pharmacological?

17
Management- non drug

• General advice
• Driving-. Holders of Large Goods Vehicle (LGV)
  and Passenger Carrying Vehicle (PCV) licences
  should notify the Driver and Vehicle Licensing
  Agency and stop driving their vehicle. Holders of
  an ordinary driving licence may still drive
  providing that symptoms are controlled, but must
  inform their motor vehicle insurance company.
  
• Occupation- if undertaking heavy work, give
  advice support. Special rules apply to some
  occupations e.g. merchant seamen, airline pilots-
  need to consult their occupational health
  department.
• Manage cardiovascular risk factors

18
Patient Case- Mrs Anne Gina

• What medication to start with if having less than
  2 episodes a week of stable angina?

19
Management-drug

• GTN spray as required
• deliver 0.4mg per metered dose- Spray one puff
  under the tongue when required. If poor response
  then try buccal.
• OR
• Sublingual GTN
• rapid onset of action
• effective for 20-30 minutes (Note deteriorate
  after 8 wks)
• PLUS
• Aspirin 75 mg daily -In chronic stable angina use
  of 75 mg of aspirin per day reduces the risk of
  sudden death or MI by 34. Consider clopidogrel
  if intolerant.
• Start a statin- reduces CHD mortality by 25-35

20
Patient Case- Mrs Anne Gina

• What if symptoms worsening or gt 2 episodes per
  week?

21
Regular Treatment- if Sympx severe or gt2 episodes
per wk

• Add in stepwise manner
• (1) beta-blockers atenolol 50-100mg unless
  contraindicated, warn not to stop suddenly, tail
  off over 4 wks.
• (2) add long-acting dihydrpyridine CCB eg
  amlodipine 5mg OD. DONT use if have aortic
  stenosis, lt1 month post MI or uncontrolled HF.
• (3) add long acting nitrate ISMN 20mg BD/TDS.
• Available in oral or patches. Start low dose
  then increase- causes headaches, postural
  hypotension, dizziness.

22
Regular Treatment- if Sympx severe or gt2 episodes
per wk

• Alternative options if intolerant to B-blockers
• Patients without LVD- use diltiazem (60mg BD/TDS)
  or verapamil (80-120mg TDS) /- ISMN
• Patients with LVD- use ISMN /- amlodipine
• If standard treatment fails try nicorandil
  (5-10mg)BD. Avoid in hypotension LVF
• Avoid combination of B-blocker with rate limiting
  CCB (verapamil/diltiazem) as risk of bradycardia/
  asystole.

23
Dont forget to refer to RACPC
24
The End