Clinical Notes : Cardiovascular Disease

161. Angina 

Angina

Definitions

Typical characteristics of angina

Diagnosis

Management

- References -

- CPD Quiz -

Definitions

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• Unstable angina 

  • is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage. (1)​

  • It is characterised by specific clinical findings of

    • prolonged (>20 minutes)

    • angina at rest

    • new onset of severe angina

    • angina that is increasing in frequency, longer in duration, or lower in threshold

    • angina that occurs after a recent episode of myocardial infarction

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• Stable angina : (2)

  • Pain occurs only in context of

    • exertion or emotional stress

    • not worsening over time

    • relieved by nitrates or rest

  • 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

• SIGN (3)

  • type of discomfort

    • often described as tight, constricting, dull, or heavy

  • location

    • often retrosternal or left side of chest and can radiate to left arm, neck, jaw, and back

  • relation to exertion

    • angina is often brought on with exertion or emotional stress and eased with rest

  • duration

    • typically the symptoms last up to several minutes after exertion or emotional stress has stopped

  • other factors

    • angina may be precipitated by cold weather or after a large meal.

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NICE (4)

• three features of angina pain can help determine a diagnosis:

  • constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms

  • pain precipitated by physical exertion

  • pain relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.

• The number of features present labels the angina

  • presence of all three features represents typical angina

  • two features signifies atypical angina

  • one or none of the three features are present, the pain is defined as non-anginal.

Diagnosis

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• A 12-lead ECG is an essential part of the assessment 

  • pathological Q waves

  • left bundle branch block

  • ST-segment and T wave abnormalities (such as flattening or inversion).

​

• The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors in individual patients : (5)

  • smoking

  • hypertension

  • diabetes

  • previous history of coronary artery disease (CAD) or other vascular disease

  • family history of CAD

  • hyperlipidaemia

  • chronic kidney disease.

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• A diagnosis of angina is less likely if the chest pain is : (4)

  • continuous and/or very prolonged

  • unrelated to activity

  • brought on by breathing in

  • associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing

Differential diagnosis of chest pain

Management

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• Unstable angina

  • oxygen

    • to maintain oxygen saturation >90%

  • glyceryl trinitrate

    • 0.3 to 0.6 mg (tablets) sublingually every 5 minutes when required, maximum 3 doses in 15 minutes

    • or 400-800 micrograms (1-2 sprays) sublingually every 3-5 minutes when required, maximum 3 doses in 15 minutes

  • morphine sulfate

    • 2-5 mg intravenously every 5-30 minutes when required

  • refer all to A+E for

    • investigation and monitoring

    • beta blocker

    • antiplatelet therapy

    • advanced interventions as required

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• Stable angina management may include :

  • lifestyle education

  • antiplatelet therapy

  • anti-anginal therapy

  • statin or other lipid-lowering therapy

  • antihypertensive therapy

  • blood sugar control

  • 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.

Access

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2, Ubnstable angina

BMJ Best Practice

Last reviewed: March 2019

Last updated: September  2018

Access

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3. Management of stable angina.

Scottish Intercollegiate Guidelines Network.

SIGN 151. Edinburgh

2018

Access

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4. Chest pain of recent onset: assessment and diagnosis.

Clinical Guideline CG95. NICE

Published date: March 2010

Last updated: November 2016

Access

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5. Stable angina: how does the SIGN guideline compare with NICE?

Begg A

Guidelines in Practice

October 2018

Access

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Acute coronary syndrome

Scottish Intercollegiate Guidelines Network.

SIGN 148

April 2016

Access

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AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes

American College of Cardiology; American Heart Association

April 2016

Access

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Australian clinical guidelines for the management of acute coronary syndromes 2016

National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand

2016

Access

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