Angina

Definition

 

Angina is chest pain or discomfort that is caused when the heart muscle does not get enough blood.

 

The question is always whether or not it is ACUTE CORONARY SYNDROME instead.

 

Epidemiology

• Roughly 10% for men and 5% for women over 55 years
• South Asian origin
• Lower socio-economic groups

 

Risk factors

• Family history
• Smoking
• Diabetes mellitus
• Metabolic syndrome
• Hyperlipidaemia
• Hypertension
• Obesity
• Lack of exercise
• Cardiac abnormalities (like hypertrophic obstructive cardiomyopathy)

 

Presentation

 

Note: If chest pain is present at the time of consultation, give some sublingual glyceryl trinitrate (GTN) and if the pain doesn't resolve within a few minutes, treat as ACUTE CORONARY SYNDROME

 

• Anginal pain (Typical = all 3, Atypical = 1 or 2)
• Constricting discomfort in the front of the chest, neck, shoulders, jaws, and arms
• Precipitated by physical exertion
• Relieved by rest or GTN in about 5 minutes

• Consider
• Risk factors as listed above
• History of cardiovascular disease
 

Differential diagnoses

• Acute myocardial infarction
• Prinzmetal's angina
• Acute pericarditis
• Musculoskeletal pain (Tietze's)
• GORD
• Pleuritic chest pain
• Aortic dissection
• Gallstones

 

Investigations

• ECG
• Pathological Q waves
• LBBB
• ST segment or T wave abnormalities
• FBC
• Renal function
• Fasting blood glucose
• Fasting blood cholesterol and triglycerides
• LFTs before statins
• TFTs
• Test troponins or cardiac enzymes
• Echocardiography

 

Management

If there are warning signs suggestive of acute coronary syndrome, referral is necessary

Conservative

• Patient informed of diagnosis and implications
• Exercise more, stop smoking, and generally reduce modifiable risk factors
• Check driving fitness
• If an attack is experienced
• Stop and rest
• Take GTN, again after 5 minutes if still not subsided, and a third time after another 5 minutes
• Call the ambulance if it still hasn't subsided

Medical

• Beta-blocker or calcium-channel blocker as first line
• Switch or combine if there is a problem
• After that, or if there are contraindications:
• Long-acting nitrate
• Ivabradine
• Nicorandil
• Ranolazine
• Other
• Aspirin or clopidogrel
• Statins
• ACE inhibitors (in those with stable angina and diabetes)

Surgical

• Coronary revascularisation

Prognosis

• 1 in 10 will suffer myocardial infarction within a year of diagnosis
• Annual total mortality rate is 5%