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ANGINA
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A form of coronary artery disease (CAD)
Classic cardiac pain that is felt when there is a reduction in blood supply to the myocardium
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▪ Most commonly due to CAD
▪ CAD → atherosclerotic plaques developing within the coronary vessels
▪ This limits blood flow and precipitates symptoms
▪ On exertion there is increased oxygen demand within cardiomyocytes
▪ The narrowing of the coronary vessels means blood flow cannot be increased to meet this demand
o It may be obstructive (>50% of vessel lumen)
o May be non-obstructive (<50% of vessel lumen)
▪ This results in myocardial ischaemia which is experienced as pain
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These include:
Prinzmetal angina (coronary artery spasm)
Microvascular angina → diffuse vascular disease within the microvasculature of the coronary circulation
Vasculitis → Kawasaki disease, polyarteritis nodosa
Anaemia → oxygen supply/demand mismatch
Severe left ventricular hypertrophy → reduced subendocardial blood flow and increased susceptibility to
ischaemia
Severe aortic stenosis → increases myocardial oxygen demand
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Stable/stenotic plaque – has a thick fibrous cap
▪ These are slow growing
▪ Fibrin cap matures and isn’t prone to rupture
▪ This will cause stable angina
▪ This can only be seen on exertional studies
→ occurs predictably with exertion and lasts <10 minutes
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Unstable/non-stenotic plaque – has a thin cap which is susceptible to rupture
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→ a sudden new onset of angina or a significant and abrupt deterioration in angina that was previously stable
e
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pain that is increased in frequency and severity or pain at rest
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CLINICAL PRESENTATION
→ ‘classic central crushing/constricting chest pain’e
▪ Central chest pain that occurs only on exertion
o Site – central chest
o Onset – after exertion (emotional or physical), resolves upon rest, can be worse after eating
o Characteristic – crushing, pressing, squeezing, constricting in nature
▪ Seems as if they are going to die
o Radiation – can commonly radiate to the shoulder, left arm, jaw and neck
o Associated symptoms –
o Time – usually lasts about 5-10 minutes, typically <10
o Exacerbating/relieving factors – GTN spray will alleviate the pain, as will resting
o Severity – may be very severe
▪ Dyspnoea
▪ Palpitations – angina may be precipitated by tachyarrhythmias (e
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AF)
▪ Syncope – may be suggestive of dangerous valvular or cardiac muscle disease causing angina
3 CLASSIC FEATURES
1
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Precipitated by physical exertion
3
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Classification → 3 types:
▪ Typical – all 3 of above features
▪ Atypical – 2 of the above features
▪ Non-anginal – 1 or less of the above features
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Non-anginal chest pain includes:
▪ Continuous or very prolonged pain
▪ Unrelated to activity
▪ Brought on by breathing
▪ Associated with dizziness, palpitations, paraesthesia, swelling difficulties
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Risk factors → high cholesterol, hypertension, smoking, diabetes, obesity, age, family history, male, premature
menopause
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Includes six clinical presentations of CAD:
i
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Suspected CAD and new heart failure (or LV dysfunction)
iii
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Known CAD (asymptomatic or symptomatic (1 year after initial diagnosis or
revascularisation
v
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CAD detected at screening (asymptomatic)
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Exclude ACS
2
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Carry out basic investigations
4
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Offer diagnostic testing
6
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(!) rapid access chest pain clinic (RACPC) (!)
Px with new onset exertional chest pain suspected to be angina should have access to this
Provide px with early access to specialist cardio assessment and diagnostic testing
Identifies new CAD and prevent major cardiac event
Offers early intervention
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g
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2nd line investigations (to consider)
The pre-test probability of CAD calculator is used to determine what further tests are required and the probable
presence of CAD
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Pre-test probability >15% → non-invasive functional testing recommended
Pre-test probability 5-15% → consider further testing based on basic ix and risk factors
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▪ Anatomical non-invasive testing
o CT coronary angiography (CTCA)
▪ Allows visualisation of coronary artery lumens
o Way of excluding CAD
o If obstructive CAD identified → px require further testing to determine significantce
o Obstructive = >70% stenosis of >1 major coronary artery segment OR >50% stenosis in the left
main coronary artery
o Offer if: low clinical likelihood of CAD or no history of CAD
▪ Non-invasive functional testing
o Dobutamine stress echocardiography
o Stress or contrast cardiac MRI
o Perfusion changes by single-photon emission CT (SPECT)
o Exercise ECG
▪ Px runs on treadmill and observe for clinical symptoms and ECG chnges suggestive of
ischaemia (ST depression)
▪ This is inferior to other non-invasive and anatomical testing
o Detects myocardial ischaemic when the heart is put under stress
o They have a high accuracy for flow-limiting coronary artery stenosis compared to invasive
functional tests at angiography

Offer if: high clinical likelihood of CAD, revascularisation therapy likely needed, or have
established CAD
Invasive coronary angiography
o Can be used both to diagnose and treat obstructive CAD
o Offer if: high clinical likelihood of CAD and symptoms are unresponsive to medical therapy,
typical angina at low activity level and high risk of cardiac event or LV dysfunction on ECHO
suspected secondary to CAD
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High risk → >3% annual risk of cardiac mortality
Low risk → <1% annual risk of cardiac mortality
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g
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Lifestyle management
→ addressing these are a major prevention strategy
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5 units/week)
▪ Smoking cessation
▪ Exercise – 30-60 mins of moderate activity
▪ Weight loss – aim for healthy BMI (18-25 kg/m2)
▪ Optimise co-morbidities
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→ 1st line treatment
▪ Px should be offered one of the following (or both)
▪ Beta blocker → metoprolol, bisoprolol (10-20 mg OD), carvedilol, nadolol
o Work by decreasing myocardial oxygen demand
▪ Calcium channel blocker → amlodipine (dihydropyridine), verapamil, diltiazem (non-dihydropyridine)
o Works by decreasing myocardial oxygen demand
o Dihydropyridine usually used
o Non-dihydropyridine CCBs are contraindicated with beta-blockers → risk of AV block
▪ ACE-inhibitors → losartan, lisinopril, captopril, enalapril
▪ Px should also be offered medications to optimise co-morbidities
o Antiplatelet therapy
▪ Aspirin 75-150 mg orally OD
▪ Clopidogrel 75 mg orally OD
▪ Continued indefinitely
▪ If ACS event happens, both are combined
o Statin
▪ Atorvastatin 10-20 mg orally OD or 40-80 mg orally OD
▪ Simvastatin 20-40 mg orally OD
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Surgical management
→ for px who are high risk of a major cardiac event or refractory to medical therapy
▪ PCI – revascularisation
o Coronary angiography with percutaneous coronary intervention (PCI)
o Insert stent into coronary artery to improve blood flow and symptoms
o May be offered to coronary arteries with significant stenosis or where flow across a diseased artery
is significantly limited
o Measured by the fractional flow reserve (FFR)
o After stent insertion for stable angina → dual anti-platelet therapy for a min of 6 months
▪ CABG
o Bypass surgery
o Restore flow within a coronary vessel by bypassing the obstructed segment
o Vein grafts or redirecting flow from the internal mammary artery
o Indications for CABG:
▪ >50% stenosis of left main stem
▪ >70% stenosis of proximal LAD and circumflex arteries
▪ >70% stenosis of proximal LAD and poor LV function (<50%) or reversible ischaemia on
diagnostic testing
▪ Triple-vessel disease (asymptomatic or symptomatic)
▪ Triple-vessel disease with proximal LAD stenosis and poor LV function
▪ One or two-vessel disease with a large area of viable but high risk myocardium in a
symptomatic px

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