Cardiology: Angina pectoris

Angina pectoris
Angina pectoris

  • Due to myocardial ischaemia, presents with chest pain or tightness that is relieved by rest
  • May radiate to jaw or arm
  • Other precipitants – emotion, cold weather and heavy metals
  • Associated symptoms – dyspnoea, nausea, sweatiness, faintness

  • Most commonly atheroma
  • Rarely – anaemia, AS, tacharrhythmias, HOCM and arteritis/small vessel disease

  • Stable angina – induced by effort relieved by rest
  • Unstable angina – angina of increasing frequency or severity (associated with increased risk of MI)
  • Decubitus angina – precipitated by lying flat
  • Prinzmental’s angina – caused by coronary artery spasm

  • ECG – may show ST depression and T wave inversion or flattening from previous MI
  • Exercise ECG
  • Thallium test
  • Coronary angiography
  • Exclude precipitating factors – anaemia, diabetes, hyperlipidaemia, thyrotoxicosis, GCA

  • Change lifestyle
  • Treat modifiable risk factors – hypertension, DM
  • Aspirin – 75-150mg/24hr, reduces  mortality by 34%
  • ?-Blockers – Atenolol 50-100mg/24hr, unless CI (asthma, COPD, LVF, bradycardia, coronary artery spasm)
  • Nitrates – for symptoms give GTN spray or sublingual tabs every 30mins. For prophylaxis take regular oral nitrate e.g. isosorbide mononitrate 10-30mg BD or slow release nitrate 60mg/24hr
  • Calcium channel antagonists – amlodipine or diltiazem
  • If total cholesterol is >4mmol/L give a statin
  • Consider adding a K+ channel activator

Percutaneous transluminal coronary angioplasty (PTCA)
  • Involves balloon dilation of the stenotic vessel
  • Indications – poor response or tolerance to medication, refractory angina in patients not suitable for CABG, previous CABG, post-thrombolysis in patients with severe stenosis or positive stress test
  • Comparison wit PTCA and drug along show that PTCA may control symptoms better but with increased risk of early cardiac event
  • Complications – restenosis (20-30% in 6mths), emergency CABG (<3%), MI (<2%), death (<0.5%)
  • Stenting reduces rates of restenosis and need for bail out CABG
  • Drug coated stents and antiplatelet drugs reduced rates of restenosis

  • Indications – left main stem disease, multiple vessel disease, distal vessel disease, patient unsuitable for angioplasty, failed angioplasty
  • Comparisons between CABG and PTCA showed that CABG was better for symptom control and had a lower reintervention rate but required a longer recovery and inpatient stay

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