Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion_Tamponade |Pneumothorax |Tension Pneumothorax |Shingles |Analgesia and Pain management

In people with angiographically normal coronary arteries and continuing anginal symptoms, consider a diagnosis of cardiac syndrome X.

About

• Can be a sign of atherosclerosis

Aetiology

• Suggests a fixed coronary stenosis > 70% that limits flow
• Angina can be seen with microvascular disease
• Angina can be seen with severe aortic stenosis

Canadian Cardiovascular Society (CCS) angina score

• Class I: Angina only during strenuous or prolonged physical activity
• Class II: Slight limitation, with angina only during vigorous physical activity
• Class III: Moderate limitation where symptoms occur with everyday activities
• Class IV: Inability to perform any activity without angina or angina at rest, i.e. severe limitation

Risk factor

Clinical

• Chest pain or equivalent occurring during periods of increased myocardial work because of reduced coronary perfusion.
• Relieved by rest with the same pattern over time
• Look for aortic stenosis, S3, Cardiomegaly Gallop rhythm
• May be peripheral vessel disease, carotid and renal bruits

Precipitants

• Exertion, meals, cold weather
• High emotion (anger, excitement).
• Anaemia, thyrotoxicosis

Differentials

• Exclude aortic stenosis, anaemia, HOCM

Investigations

• FBC, U&E, Lipids, Glucose
• ECG: May show ST depression with pain but usually normal, LVH
• Exercise stress test: ST depression with exercise
• Echocardiogram; assess LV
• Stress Echocardiogram both during resting and under stress (dobutamine) may show abnormal ventricular wall function.
• CT Coronary can show calcification of coronary arteries.
• Thallium-201 uptake scan may show areas of infarction and reversible ischaemia
• Coronary angiogram if planned intervention but the risk of stroke, death and other complications

QRIKS score

Note: The QRISK score is calculated using a validated algorithm that assigns specific weights to each of these factors to estimate a patient's 10-year risk of developing cardiovascular disease. This table provides an overview of the factors considered but does not replace the actual QRISK calculator.

Risks assessment

• High: Post-infarct angina, Poor effort tolerance, Ischemia at low workload, Left main or three-vessel disease, Poor left ventricular function
• Low: Predictable exertional angina, Good effort tolerance, Ischemia only at high workload, Single-vessel or two-vessel disease, Good left ventricular function

Investigations

Management

• Smoking cessation
• Regular exercise within limits
• Weight loss, Healthy diet
• Diabetes and BP management as needed.
• Medications
  • Antiplatelet - Aspirin 75 mg (81 mg US) daily is usual
  • Short acting Nitrates
    • Sublingual GTN spray 400 mcg/spray can be useful for angina not relieved quickly by rest. Can cause flushing, headache and light-headedness . Warn patient. Sit down. Repeat the dose after 5 minutes if the pain has not gone. Call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose.
  • Long-acting nitrates
    • Isosorbide dinitrate (10-20 mg 3 times daily) PO
    • Isosorbide mononitrate (20-60 mg once or twice daily) PO
    • GTN patch 5-10 mg per day is another way to give nitrates
  • Beta blockers: reduce the oxygen demand e.g. Bisoprolol (5-10 mg daily)
  • Calcium antagonists
    • Diltiazem 60-120 mg TDS
    • Nifedipine 5-20 mg TDS
    • Nicardipine 20-40 mg TDS
    • Amlodipine 2.5-10 mg OD
    • Ultra-long-acting Verapamil 40-80 mg TDS
  • Potassium channel openers: Vasodilator Nicorandil 10-30 mg BD PO
  • Ivabradine: causes a bradycardia and used where beta blockers cannot. Does not reduce contractility
  • Ranolazine: blocks late inward sodium current in coronary and reduces vascular tone and reduces angina
  • Lipid lowering with a Statin e.g Atorvastatin
  • ACE inhibitors if stable angina and diabetes
• Coronary angiogram and PCI stenting if worsening for those with stable angina and suitable coronary anatomy when symptoms are not satisfactorily controlled with optimal medical treatment and revascularisation is considered appropriate and CABG is not appropriate
• Coronary artery bypass grafting: In patients with triple vessel disease or left main stem coronary artery disease, surgery improves outcome. Grafts now include internal mammary or radial artery or reversed saphenous vein grafts. Mortality is 1-2%

References

Revisions