Understanding Angina: A Guide for Junior Doctors

Angina pectoris, often referred to simply as "angina," is a clinical syndrome characterized by chest pain or discomfort due to myocardial ischemia. This blog post will teach junior doctors how to approach a patient with suspected angina, covering history-taking, examination, investigations, and management.

History Taking: Key Questions

Start by establishing the nature of the chest pain. Use the SOCRATES framework:

·     Site

o   Where is the pain located?(Classically retrosternal, but may radiate to the neck, jaw, shoulders, or arms—commonly the left arm.)

·     Onset

o   When did it start? Was it gradual or sudden?(Angina is typically triggered by exertion or emotional stress.)

·     Character

o   How would you describe the pain?(Patients often describe it as a pressure, heaviness, or squeezing sensation.)

·     Radiation

o   Does the pain travel anywhere?(Pain radiating to the jaw, neck, or arms is typical.)

·     Associated Symptoms

o   Do you feel shortness of breath, nausea, or sweating?(These symptoms can accompany angina.)

·     Timing

o   How long does the pain last?(Stable angina lasts a few minutes and resolves with rest or nitrates.)

·     Exacerbating/Relieving Factors

o   What makes it worse or better?(Pain is usually relieved by rest or nitroglycerin. Exertion or cold weather often aggravates it.)

·     Severity

o   On a scale of 1 to 10, how bad is the pain?(Severity is subjective but may help monitor changes over time.)

Additional Questions

·       Risk Factors

o   Do you smoke, have high blood pressure, diabetes, or high cholesterol?

o   Is there a family history of cardiovascular disease?

·       Previous Episodes

o   Have you had similar chest pain before?

·       Drug History

o   Are you taking any medications, including antiplatelet or nitrates?

Examination Findings

·     General Appearance

o   Look for pallor, diaphoresis, or respiratory distress.

·     Vital Signs

o   Measure blood pressure (in both arms if aortic dissection is a differential).

o   Check heart rate and rhythm.

·     Cardiovascular Examination

o   Inspect for scars (previous surgery), signs of heart failure (e.g., peripheral edema, raised JVP).

o   Palpate the chest for tenderness (to rule out musculoskeletal pain).

o   Auscultate for heart murmurs (e.g., aortic stenosis), gallops, or pericardial rubs.

·     Respiratory Examination

o   Look for signs of pulmonary congestion, such as crackles at lung bases.

·     Other Relevant Signs

o   Assess for xanthelasma or corneal arcus (signs of hyperlipidemia).

Investigations

·       Bedside Tests

• ECG

  • Look for ischemic changes: ST depression, T-wave inversion, or left bundle branch block.

  • Note: A normal ECG does not exclude angina.

• Blood Glucose

  • To rule out diabetes as a risk factor.

• Pulse Oximetry

  • Assess oxygen saturation.

·       Blood Tests

• Cardiac Biomarkers (Troponins)

  • Elevated levels suggest myocardial infarction, not stable angina.

• Lipid Profile

  • To assess cardiovascular risk.

• HbA1c

  • To evaluate long-term glycemic control in diabetics.

• Renal Function Tests

  • To guide medication choices like ACE inhibitors.

·       Imaging

• Chest X-ray

  • Rule out alternative diagnoses like pneumonia or cardiomegaly.

• Stress Testing (Exercise ECG)

  • Assess for exercise-induced ischemia.

• CT Coronary Angiography (CTCA)

  • Recommended as the first-line imaging in stable chest pain according to NICE guidelines.

• Coronary Angiography

  • Definitive for assessing coronary artery stenosis, especially if invasive intervention is planned.

Management Plan

·       Initial Management in Acute Setting

·       Relieve Ischemia

o   Sublingual Nitroglycerin (GTN): One spray under the tongue.

o   Provide oxygen if SpO₂ < 94%.

·       Symptom Control

o   Administer analgesia if needed (e.g., morphine for severe pain).

·       Monitor

o   Attach the patient to continuous ECG monitoring.

Long-term Management

·       Lifestyle Modifications

·       Encourage smoking cessation, weight loss, regular exercise, and a Mediterranean diet.

·       Medications

·       Anti-anginal Drugs

o   Beta-blockers (e.g., bisoprolol): First-line therapy.

o   Calcium Channel Blockers (e.g., amlodipine): As an alternative or in combination.

o   Nitrates: For symptomatic relief.

·       Cardiovascular Risk Reduction

o   Antiplatelet Therapy (e.g., aspirin 75 mg daily).

o   Statins (e.g., atorvastatin 40-80 mg daily).

o   ACE Inhibitors (e.g., ramipril) if hypertensive, diabetic, or post-MI.

Interventional Options

·       Percutaneous Coronary Intervention (PCI): For severe stenosis or unstable angina.

·       Coronary Artery Bypass Grafting (CABG): For multi-vessel disease.

Red Flags Requiring Immediate Escalation

·       Chest pain at rest or not relieved by nitrates.

·       Signs of acute heart failure or hemodynamic instability.

·       New-onset chest pain in a patient with a history of coronary artery disease.