Clinical Notes : Cardiovascular Disease
161. Angina

Angina
Definitions
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Unstable angina
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is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage. (1)
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It is characterised by specific clinical findings of
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prolonged (>20 minutes)
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angina at rest
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new onset of severe angina
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angina that is increasing in frequency, longer in duration, or lower in threshold
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angina that occurs after a recent episode of myocardial infarction
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Stable angina : (2)
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Pain occurs only in context of
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exertion or emotional stress
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not worsening over time
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relieved by nitrates or rest
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ECG may be normal in the absence of pain but may show ST depression during episodes of angina or on stress testing.
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Typical characteristics of angina
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SIGN (3)
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type of discomfort
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often described as tight, constricting, dull, or heavy
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location
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often retrosternal or left side of chest and can radiate to left arm, neck, jaw, and back
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relation to exertion
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angina is often brought on with exertion or emotional stress and eased with rest
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duration
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typically the symptoms last up to several minutes after exertion or emotional stress has stopped
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other factors
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angina may be precipitated by cold weather or after a large meal.
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NICE (4)
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three features of angina pain can help determine a diagnosis:
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constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms
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pain precipitated by physical exertion
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pain relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.
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The number of features present labels the angina
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presence of all three features represents typical angina
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two features signifies atypical angina
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one or none of the three features are present, the pain is defined as non-anginal.
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Diagnosis
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A 12-lead ECG is an essential part of the assessment
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pathological Q waves
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left bundle branch block
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ST-segment and T wave abnormalities (such as flattening or inversion).
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The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors in individual patients : (5)
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smoking
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hypertension
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diabetes
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previous history of coronary artery disease (CAD) or other vascular disease
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family history of CAD
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hyperlipidaemia
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chronic kidney disease.
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A diagnosis of angina is less likely if the chest pain is : (4)
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continuous and/or very prolonged
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unrelated to activity
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brought on by breathing in
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associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing
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Differential diagnosis of chest pain

Management
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Unstable angina
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oxygen
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to maintain oxygen saturation >90%
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glyceryl trinitrate
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0.3 to 0.6 mg (tablets) sublingually every 5 minutes when required, maximum 3 doses in 15 minutes
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or 400-800 micrograms (1-2 sprays) sublingually every 3-5 minutes when required, maximum 3 doses in 15 minutes
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morphine sulfate
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2-5 mg intravenously every 5-30 minutes when required
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refer all to A+E for
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investigation and monitoring
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beta blocker
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antiplatelet therapy
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advanced interventions as required
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Stable angina management may include :
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lifestyle education
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antiplatelet therapy
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anti-anginal therapy
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statin or other lipid-lowering therapy
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antihypertensive therapy
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blood sugar control
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revascularisation
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1. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
Roffi M, Patrono C, Collet JP, et al.
European Society of Cardiology (ESC).
Eur Heart J. 2016 Jan 14;37(3):267-315.
2, Ubnstable angina
BMJ Best Practice
Last reviewed: March 2019
Last updated: September 2018
3. Management of stable angina.
Scottish Intercollegiate Guidelines Network.
SIGN 151. Edinburgh
2018
4. Chest pain of recent onset: assessment and diagnosis.
Clinical Guideline CG95. NICE
Published date: March 2010
Last updated: November 2016
5. Stable angina: how does the SIGN guideline compare with NICE?
Begg A
Guidelines in Practice
October 2018
Acute coronary syndrome
Scottish Intercollegiate Guidelines Network.
SIGN 148
April 2016
AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes
American College of Cardiology; American Heart Association
April 2016
Australian clinical guidelines for the management of acute coronary syndromes 2016
National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand
2016




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