QuestionSBA
QuestionChoice
Ranolazine is a potassium channel activator. NICE guidelines suggest adding ranolazine only after considering the use of both a calcium channel blocker and beta-blocker
32281
d
Ranolazine
QuestionChoice
Ivabradine blocks sodium channels in the sinus node. NICE guidelines suggest adding ivabradine only after considering the use of both a calcium channel blocker and a beta-blocker
32282
e
Ivabradine
QuestionChoice
NICE guidelines suggest that the first-line management for patients with angina is either a beta-blocker (e.g. bisoprolol) or a calcium-channel blocker (e.g. amlodipine). The initial drug should be up-titrated before switching to the other option or using a combination of the two
32278
a
Add amlodipine
QuestionChoice
ISMN is a long-acting nitrate. NICE guidelines suggest adding ISMN only after considering the use of both a calcium channel blocker and beta-blocker
32280
c
Add isosorbide mononitrate (ISMN)
QuestionChoice
Verapamil is a non-dihydropyridine calcium channel blocker that acts on the heart. It should not be combined with a beta-blocker due to the risk of heart block
32279
b
Add verapamil
QuestionComment
I thought you SHOULD give a non-dihydropyridine as it acts on the heart directly, compared to non-rate limiting CCBs which would cause widespread vasodilation and so induce tachycardia as a reflex...which would worsen the angina? no?
22317
QuestionComment
on research, is this correct to assume then:
- give a non-dihydro. as first line if BB contraindicated
- give a dihydro. if must be given with a BB as second line, due to risk of heart block (if non-dihydro. given in conjunction with a BB)
...is this correct? any help would be great cheers
22318
User
subscriber
Thermoregulator Endoscope
QuestionComment
Yep - you've got it
22881
User
subscriber
Supine Body
User
subscriber
Thermoregulator Endoscope
Concept
Chapter
# Summary

Stable angina, characterised by chest pain triggered by myocardial ischemia, is most commonly caused by coronary artery disease. Typical anginal chest pain is described as an exertional chest discomfort that may radiate to the jaw/neck/arm and that is alleviated by rest (<5 minutes) or with GTN spray. Diagnosis involves investigations such as ECG, blood tests, and CT coronary angiogram. Management includes conservative measures to optimise cardiovascular risk factors, medical treatment with anti-anginal medications, and revascularisation options like coronary artery bypass graft or percutaneous coronary intervention in cases not controlled by medical therapy.

# Definition 

Typical anginal chest pain is defined by the following 3 features:

1. Constriction/heavy discomfort to chest that may radiate to the jaw/neck/arm.
2. Brought on by exertion.
3. Alleviated by rest (<5 minutes) or GTN spray. 

3/3 features = typical angina pain 

2/3 features = atypical angina pain

0-1/3 features = non-anginal pain 

# Epidemiology 

A 2020 Health Survey for England estimated prevalence in all UK adults as 3%, increasing to a prevalence of 10–12% in women aged 65–84 years and 12–14% in similarly aged men. 

# Pathophysiology

Stable angina occurs as a result of a mismatch of myocardial oxygen supply and demand. Most commonly, stable angina is due to coronary artery disease. Coronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. When demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. 

Other rarer causes of stable angina include anaemia, aortic stenosis, or hypertrophic cardiomyopathy.
 
# Classification 
 
Stable angina pain can be considered by its limitations on day-to-day activity:

* Class I: no angina with normal physical activity. Strenuous activity may cause symptoms. 
* Class II: angina pain causes slight limitation on normal physical activity. 
* Class III: angina causes marked limitation on normal physical activity. 
* Class IV: angina occurs with any physical activity and may occur at rest (see unstable angina). 

# Symptoms and Signs

* Central, constricting chest pain that radiates to neck/jaw/arm. 
* Exertional chest pain that is relieved on rest/GTN. 
* Associated symptoms: nausea, vomiting, clamminess or sweating. 

Stable angina may have no clinical signs on examination at rest.

# Differential Diagnoses 

* **Acute Coronary Syndrome (ACS)** 
	* **Similarities**: cardiac-sounding chest pain as a presenting complaint for both. Similar patient profile with significant risk factors for coronary artery disease. 
	* **Differences**: stable angina only occurs on exertion and is alleviated by rest. ACS chest pain occurs at rest. 

* **Gastro-oesophageal reflux disease (GORD)** 
	* **Similarities**: both may present with central chest discomfort/pain. 
	* **Differences**: discomfort in stable angina commonly described as a squeezing or pressure-like pain brought on by exertion. GORD-related chest discomfort often described as a burning sensation that is triggered by certain foods, alcohol, or lying down. 

* **Costochondritis** 
	* **Similarities**: both present with chest pain. 
	* **Differences**: costochondritis refers to inflammation of the cartilage connecting ribs to the sternum. The pain is described as sharp and can be reproduced by pressing on the chest wall. 

* **Pleuritic Chest Pain e.g. Pulmonary Embolism, Pneumonia** 
	* **Similarities**: both present with chest pain or discomfort. 
	* **Differences**: pleuritic chest pain is often described as sharp and worse on inspiration. Pleuritic chest pain will also be accompanied by clinical features relating to the underlying cause e.g. productive cough, fevers, risk factors for VTE, or a hot swollen calf. 

Other differential diagnoses include anxiety, aortic dissection (radiates to the back), and other causes of musculoskeletal chest pain. 

# Investigations

Once atypical/typical anginal pain is suspected: 

**Routine investigations in primary care**: 

* ECG - to assess for ischaemic changes or previous MI. 
* Bloods - FBC and TFTs (to exclude anaemia and hyperthyroidism respectively which can exacerbate angina symptoms).
* Consider cardivascular risk factors: hypertension, hypercholesterolaemia, diabetes mellitus, smoking. 

**1st line investigations**

* CT coronary angiogram (CT CA)- indicated if typical/atypical angina pain or if ECG shows ischaemic changes in chest pain with <2 angina features.

**2nd line investigations** 

If CTCA is inconclusive the patient may undergo functional imaging: 

* Stress echocardiogram 
* Myocardial perfusion SPECT 
* Cardiac MRI

**3rd line investigations**

Invasive coronary angiography can be performed if there are inconclusive results from non-invasive testing.

# Management

## Conservative management

Conservative management involves the optimisation of cardiovascular risk factors to reduce the atherosclerotic process.  

* Smoking cessation
* Glycaemic control
* Hypertension
* Hyperlipidaemia
* Weight loss
* Alcohol intake 

## Medical management 

* Secondary prevention: aspirin 75mg OD  and statin 80mg ON. 
* GTN spray for symptom relief: inform patient of side-effects (headache, flushing, dizziness) and to repeat dose if pain not stopped after 5 minutes. 

*Emergency help should be sought if pain not subsided after 2 doses of GTN as this may indicate acute coronary syndrome.* 

**Anti-anginal medications**

**1st line** = beta-blocker (bisoprolol) OR calcium channel blocker (verapamil or diltiazem). *Do not combine due to risk of heart block*. 

If taking a beta-blocker and symptoms are uncontrolled, switch to, or add, a long-acting dihydropyridine calcium-channel blocker (CCB), such as amlodipine, modified-release nifedipine. If taking a non-dyhydropyridine calcium channel blocker already, switch to a beta blocker.

If neither can be tolerated, consider a long-acting nitrate (ISMN), ivabradine, nicorandil or ranolazine.  

**2nd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker (amlodipine or nifedipine)

**3rd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker AND long-acting nitrate.

A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. At this stage, revascularisation with PCI or CABG must be considered. 

## Revascularisation

Revascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with:  

* Symptoms which are not controlled by optimal medical management.
* Complex 3 vessel disease and/or significant left main stem on CTCA. 

# NICE Guidelines

[NICE Guidance on Cardiac-Sounding Chest Pain](<https://www.nice.org.uk/guidance/cg95/chapter/Recommendations>) 

[NICE Guidance on Stable Angina](<https://www.nice.org.uk/guidance/cg126/chapter/Guidance>) 

# References

[Patient UK Information on Stable Angina](<https://patient.info/doctor/stable-angina-2>) 
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Quesmed Tutorial: Cardiology
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In patients with stable angina, combining a beta-blocker with a calcium-channel blocker can enhance symptom control when monotherapy is insufficient.
A 56-year-old man with a history of angina presents to his GP with central chest pain on exercise that is now occurring more frequently. The pain usually lasts a few minutes and is relieved by sublingual glyceryl trinitrate (GTN) spray. He denies any pain at rest, and an ECG shows no ischaemic changes.

His only current medications anti-anginal medication is bisoprolol which has been up-titrated to the maximum tolerated dose.

Which of the following is the next step in management?
a