1. MANAGING ANGINA JIM McLENACHAN, CONSULTANT CARDIOLOGIST, LEEDS. 17 th November 2011

3. Myocardial Ischaemia Myocardial Demand (work) Myocardial Supply (blood flow)

4. What is angina ? “not a pain” tightness, pressure, heaviness usually in centre of chest may radiate to either arm, neck, jaw usually provoked by exercise (walking) usually relieved by rest lasts no more than 2 minutes

5. Differential diagnosis Dyspepsia Musculoskeletal pain Undiagnosed !!

6. Baseline investigation of suspected angina: Examination – HR, BP, murmurs ECG FBC U and E Cholesterol Glucose

7. Resting ECG Limited value Useful if evidence of old MI Normal ECG does not exclude extensive coronary disease

10. NICE Clinical guideline 95 (published March 2010) Estimate risk according to: - non-anginal, atypical, typical angina - age - sex - low or high risk

11. NICE definition of angina constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms precipitated by physical exertion relieved by rest or GTN within about 5 minutes. 3 out of 3 = typical angina 2 out of 3 = atypical angina 0/1 out of 3 = non-anginal pain

12. NICE Guidance CG95 Chest pain of recent onset Estimation of risk Non-anginal chest painAtypical anginaTypical angina MenWomenMenWomenMenWomen Age (years) LoHiLoHiLoHiLoHiLoHiLoHi 353 11985923930881078 45947222217054351922079 5523594254579104780953882 6549699297186205193975684 Table 1 Percentage of people estimated to have coronary artery disease according to typicality of symptoms, age, sex and risk factors

13. NICE Clinical guideline 95 (published March 2010) Risk <10% - no tests (!) Risk 10-29% - Cardiac CT scanning Risk 30-60% - Functional imaging Risk > 60% - Coronary angiography

14. Coronary CT scanning Some technical difficulties Beta blockers needed to slow heart rate Very sensitive test Negative result is useful Positive result needs more tests!

15. Functional imaging Stress myocardial perfusion scanning Stress echo Stress MR imaging

16. Interpretation of Myocardial Perfusion Studies Stress RestInterpretation Image Image Normal Fixed defect (infarction) Reversible defect (ischaemia)

17. CARDIAC MRI

19. Angiography in stable angina Diagnostic doubt Ischaemia at low workload Young patients Ongoing symptoms Threatened employment

20. DAY CASE CORONARY ANGIOGRAPHY Performed under local anaesthetic Duration 20 – 30 minutes Arterial access via femoral, brachial or radial artery. Complications rare: stroke / MI-< 1 in 1,000 haematoma-5 – 10 %

21. IS ANGIOGRAPHY THE GOLD STANDARD? If uncertainty persists, - intravascular ultrasound - pressure wire assessment

22. Initial treatment of suspected angina: Aspirin 75 mg once daily GTN spray (with advice) Beta blocker (eg. bisoprolol 5mg once daily) Statin

23. Treatment of Angina Aspirin Short acting nitrate Beta blocker Statin ACE inhibitor Underlined classes are for secondary prevention and are likely to be life-long.

24. NICE Clinical guidelines (CG126) 1 st line drugs Beta blockers eg. Bisoprolol Cacium channel blockers eg. diltiazem

25. NICE Clinical guidelines (CG126) 3 rd line drugs ( after beta blockers and calcium channel blockers) a long-acting nitrate or ivabradine or nicorandil or ranolazine

26. Treatment of Stable Angina Medical treatment PCI CABG

28. Stenting and the need for emergency CABG

29. CLOPIDOGREL Use instead of aspirin if genuine aspirin intolerance. Consider aspirin plus PPI in aspirin-induced dyspepsia. Give for 12 months following ACS admission After stenting: 3 months - bare metal stent, elective 12 months – any drug-eluting stent, any ACS

32. Criticism of cardiologists’ management of angina Chest pain OP assessment Exercise test Coronary angiogram PCI

33. Criticism of cardiologists’ management of angina Chest pain OP assessment Exercise test Coronary angiogram PCI one cardiologist

34. Treatment of Stable Angina.....the oculostenotic reflex............to a man with a hammer, everything looks like a nail....

35. Treatment of Stable Angina NICE Clinical Guideline 126 (published July 2011) Optimising medical treatment Demonstration of ischaemia Importance of MDT discussion

36. NICE Clinical guideline 126 (published July 2011) The main purpose of revascularisation is to improve the symptoms of stable angina. CABG and PCI are effective in relieving symptoms. Repeat revascularisation may be necessary after either CABG or PCI and the rate is lower after CABG. Stroke is uncommon after either CABG or PCI, and the incidence is similar between the two procedures. There is a potential survival advantage with CABG for some people with multivessel disease.

37. Treatment of refractory angina Is it really angina? Stellate ganglion blocks EECP

38. NICE Clinical guideline 126 (published July 2011) Do not offer the following interventions to manage stable angina: transcutaneous electrical nerve stimulation (TENS) enhanced external counterpulsation (EECP) acupuncture

39. CLASSIFICATION OF ANGINA / MI STABLE ANGINA ACUTE CORONARY SYNDROMES -unstable angina -non ST segment elevation MI (NSTEMI) -ST segment elevation MI (STEMI)

40. Pathophysiology of ACS Stable angina ST elevation MI STEMI Non ST elevation MI NON-STEMI Unstable angina

41. Myocardial Infarction More prolonged chest pain More severe chest pain More systemic upset (nausea, sweating, etc.)

42. Non-ST Elevation MI Chest pain may be new onset, or more readily induced, or more prolonged than “normal” ECG may show –transient ST elevation –ST segment depression –T-wave inversion –nothing Diagnosis often based on troponin

43. Troponin Very sensitive - normal troponin 12 hours after onset of pain effectively “rules out” ischaemic pain. Not very specific - also raised in patients with heart failure, renal failure, atrial fibrillation etc.

44. Non-ST Elevation MI Aspirin Clopidogrel (for 12 months) Heparin (Fondaparinux) Statin Beta blockers Early angiography (within 48 hours) followed by PCI / CABG as appropriate.

45. Newer antiplatelet agents Prasugrel Ticagrelor

46. ACUTE ANTEROSEPTAL MYOCARDIAL INFARCTION

47. TREATMENT OF ST ELEVATION MI ASPIRIN BETA BLOCKERES THROMBOLYSIS- Streptokinase - TPA - Reteplase - Tenectaplase PCI

48. Primary PCI vs. Thrombolysis M ortality Percent 95% CI 0.73 [0.06,0.86] PCILytic 95% CI 0.70 [0.58,0.85] All Patients No SHOCK Patients PCI Lytic Lancet 2003; 361:13-20

49. Percent Lancet 2003; 361:13-20 Reinfarction Total Stroke Haemorrhagic Stroke Death, reinfarction, stroke p<0.0001 p=0.0004p<0.0001 Primary PCI vs. Thrombolysis

50. Author: Dr Huon Gray, Consultant Cardiologist, Southampton. 20 th October, 2008

51. Median Call-to-Balloon times (minutes)

52. Mortality: PPCI direct admissions (DTB time)

54. PCI in coronary disease 35% STEMI (1,100 per annum) 40% NSTEMI 25% stable angina

56. PPCI and lysis - England %

57. 30 day STEMI mortality (source: MINAP Tenth Public report 2011) %

58. Summary Stable angina NSTEMI STEMI