B-QuiCK: Angina

B-QuiCK: Management of stable angina pectoris

Diagnosis

Patient presents with current or recent (i.e. past few days) chest discomfort:

1. Confirm symptom history and identify any acute chest pain red flags for ED referral, such as:
• Chest discomfort at rest or on minimal exertion, lasting longer than 15 minutes, that is progressing rapidly despite treatment or concurrent features of haemodynamic compromise, e.g. hypotension, tachycardia, peripheral cyanosis
2. Determine the origin of symptoms, i.e. exclude non-cardiac causes (Table 1)
• Perform a clinical examination and identify any co-morbidities or risk factors that could explain symptoms
• Arrange 12-lead ECG. Compare results to previous ECG recordings (if available), or discuss with a colleague (or cardiologist) if there is uncertainty regarding management; do not exclude a cardiac diagnosis based on a normal ECG
• Refer immediately to secondary care if ECG suggests ischaemia in a patient with new or worsening chest discomfort, e.g. ST-elevation or depression, pathological Q waves or left or right bundle branch block
• Collect a blood sample for serum troponin at initial presentation, if possible. Arrange urgent assay in a community laboratory, or send with patient to hospital, depending on their clinical condition.
• Other relevant laboratory tests include FBC (specifically haemoglobin to exclude anaemia), electrolytes (e.g. potassium) and creatinine (and calculated eGFR), HbA_1c, BNP (if heart failure suspected), TSH (if evidence of thyroid dysfunction), CRP (if infection suspected)
• Consider arranging chest X-ray for patients with atypical symptoms suggesting a pulmonary origin
3. Rule out other types of cardiac dysfunction, if possible, e.g. aortic stenosis (Table 2)
4. Establish a suspected diagnosis of angina
• Initiate treatment (see below) and refer patient for a non-acute cardiology assessment to undergo further assessment and receive a formal diagnosis
• Advise patient to seek immediate medical attention if symptoms worsen before their next appointment

Management

Reduce future cardiovascular event risk (Table 3)

Prescribe:

• Aspirin (or clopidogrel) unless contraindicated
• A statin regardless of LDL-C (or optimise existing treatment)
• An ACE inhibitor (or ARB) if the patient has hypertension or renal impairment
• A SGLT-2 inhibitor if the patient has type 2 diabetes or heart failure

Control angina symptoms (Figure 2)

Prescribe:

• A beta blocker or calcium channel blocker first-line
• Consider combination treatment if monotherapy does not adequately relieve symptoms
• Long-acting nitrates (as monotherapy) if first-line options are not tolerated, or in addition to first-line options if symptoms are not adequately controlled
• GTN spray for acute symptom relief. N.B. GTN spray can also be used prior to activities that trigger symptoms, e.g. exercise, sexual intercourse.

Medicines optimisation

• At 2 – 4 weeks post-initiation - evaluate clinical response and adverse effects from anti-ischaemic medicines
• Initiate additional anti-ischaemic medicines depending on the symptom frequency and severity
• At 12 weeks post-initiation - re-check lipid profile and optimise LDL-C-lowering treatment (as required)
• Discuss patients with refractory symptoms despite taking maximum tolerated doses with a cardiologist; more invasive management (i.e. revascularisation) may be required

Ongoing monitoring

• Annually review treatment response and symptom stability, medicines adherence and cardiovascular risk profile for stable patients or sooner (e.g. every six months) in those with poorly controlled symptoms, multiple co-morbidities or a new diagnosis
• Measure weight and waist circumference, perform 12-lead ECG and arrange relevant laboratory testing
• Regularly discuss lifestyle changes, e.g. reduce salt and saturated fat intake, regular exercise, smoking cessation (if relevant)
• Recommend cardiac rehabilitation, however, there may be a cost associated with some programmes
• Symptom recurrence after a period of successful management is suggestive of disease progression; ensure medicines are optimised before referring back to cardiology for further evaluation