Angina Pectoris

Angina Pectoris

·        Symptom complex characterised by attacks of chest pain, causing ischaemia but not infarction

·        Patterns:

o   Stable angina (typical): pain on exertion, relieved by rest or vasodilators. Subendocardial ischaemia with ST-segment depression

o   Variant or Prinzmetal‟s angina: classically occurs at rest. Caused by reversible spasm in normal to severely atherosclerotic coronary arteries. Can see ST-segment elevation or depression

o   Unstable angina: variable, prolonged pain, pain at rest or worsening of pain in stable angina.  ST-  segment depression – but may be elevated. Most common complication: arrhythmias (especially VF). Within 3 months 4% will have sudden death and 15% a myocardial infarct

o   Sudden cardiac death. Usually within an hour of a cardiac event or without symptoms. Usually high-grade stenosis. Usually associated with arrhythmias, especially ventricular ectopic beats and subsequent VF

·        Treatment options for stable angina:

o   Nitrates: short & long acting

o   b-blockers (¯myocardial O2 consumption)

o   Ca antagonists

o   Aspirin

·        Unstable angina:

o   = Acute Coronary Syndrome (ACS) = acute heart problems without ST elevation

o   Investigations:

§  ECG.  Serial or continuous if high risk

§  Bloods: Troponin (repeat after 6 hours), FBC, Cr, electrolytes, CK, blood glucose. Want to test lipids/cholestrol – but false positives following an acute coronary event. Do later.

§  CXR: cargiomegaly?  Pulmonary oedema?  Dissection?

o   Medical therapy:

§  Aspirin: reduces progression to MI. Neither Warfarin nor Heparin confers little further benefit. Use heparin if high risk.

§  b-blockers: reduce progression to MI

§  iv nitroglycerine for symptomatic relief

§  Maybe calcium channel blockers that reduce the heart rate

o   Low risk:

§  Normal ECG and no detectable troponin despite ­angina frequency or severity

§  Management: discharge for outpatient assessment

o   High risk:

§  If even a minor degree of ST depression or a significant elevation of troponin ® minor myocardial damage so now is the time to act

§  Overlap between High Risk ACS and non-STEMI (non-ST elevation MI)

§  Management: Admit for coronary angiography and, if positive, early percutaneous coronary intervention (ie more aggressive treatment than previously)

·        Long term management:

o   ¯Obesity, diabetes, smoking, ­exercise

o   Referral to a cardiac rehabilitation programme

o   Statins if serum cholesterol raised

o   ACE inhibitors if hypertension or diabetes