1. Cardiac update for GPs - Chest pain/angina Sanjay Sastry Consultant Cardiologist Royal Bolton Hospital Royal Bolton Hospital Manchester Heart Centre Wigan Infirmary

2. Started as consultant at Bolton in May 2007 General cardiology and on calls at Bolton Angiography and angioplasty/stent procedures at MRI and Wigan On calls for the Greater Manchester Heart Attack service (for STEMI) at MRI

3. Assessment of new onset chest pain in primary care Case-based approach Antianginal and cardiac medications Chest pain/angina

4. Features of stable angina Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms Precipitated by physical exertion Relieved by rest or GTN in about 5 minutes People with – Non-anginal chest pain have one or none of these features Atypical angina: two features Typical angina: all three features

5. Physical examination – atrial fibrillation, heart murmur Exclude a diagnosis of stable angina if the pain is non- anginal Normal 12-lead ECG does not exclude angina FBC to exclude anaemia Excluding other causes of angina/chest pain

6. Case 1 75 year old female Smoker Normal BP; cholesterol 4.5 Exertional central chest heaviness after walking uphills relieved with rest Examination normal

7. Case 1 - Management plan Refer to rapid access chest pain clinic 12-lead ECG Bloods including FBC Start Aspirin 75mg od and GTN spray PRN

9. Case 2 34 year old male Family history of CAD Normal BP; cholesterol 5.0; not diabetic; non- smoker Chest tightness at night No exertional symptoms Relieved spontaneously after 30 mins Normal examination

10. Case 2 - Management plan 12-lead ECG Bloods including FBC Refer to general cardiology clinic – non- anginal symptoms

12. Case 3 45 year old female Hypertension; Diabetes mellitus on diet Cholesterol 5.0; non-smoker Central chest pain brought on with exertion and at rest Relieved spontaneously after 5 mins Normal examination

13. Case 3 - Management plan 12-lead ECG Bloods including FBC Start Aspirin 75mg od and GTN spray PRN Refer to Rapid Access Chest Pain clinic

15. Case 4 65 year old male Previous MI; CABG 10 years ago Hypertension; Diabetes mellitus on diet; treated hyperlipidaemia Non-smoker 3 month history of sharp chest pain brought on with exertion Relieved with GTN spray Normal examination

16. Case 4 - Management plan 12-lead ECG Bloods including FBC Refer to General Cardiology clinic for Urgent review Not suitable for Rapid Access Chest Pain clinic currently

17. Diagnostic testing for new onset chest pain Estimated likelihood of CAD 10–29% Estimated likelihood of CAD 30–60% Estimated likelihood of CAD 61–90% Offer CT calcium scoringOffer non-invasive functional imaging Offer invasive coronary angiography if appropriate If CT calcium score is: zero, investigate other causes of chest pain 1–400, offer 64-slice (or above) CT coronary angiography >400, follow pathway for 61–90% CAD If reversible myocardial ischaemia uncertain, offer invasive coronary angiography Offer non-invasive functional imaging if invasive coronary angiography not appropriate If significant CAD uncertain, offer non- invasive functional imaging

18. Medications in angina treatment Antiplatelet treatment: Aspirin 75mg od Clopidogrel (if Aspirin allergy/intolerance) GTN spray 1-2 puffs PRN

19. Antianginal treatment – test yourself! True or False? 1.Betablockers are first line therapy for angina in diabetes 2.Betablockers are not contra-indicated in patients with COPD 3.Nicorandil may cause hypotension and mucosal ulceration 4.Ranolazine does not cause bradycardia or hypotension 5.Ivabradine may be used in conjunction with betablockers 6.Long-term use of oral nitrates may result in tolerance to nitrates

20. Medications in angina treatment Antianginal treatment: First line therapy: Betablockers e.g. Atenolol 25-50mg, Bisoprolol 2.5- 10mg reduce myocardial oxygen demand and improve coronary blood flow Rate-limiting calcium channel blockers e.g. Diltiazem 180-240mg, Verapamil 120-240mg

21. Antianginal treatment Second line therapy: Amlodipine or Felodipine Nicorandil Isosorbide Mononitrate Other options: Ranolazine Ivabradine (if intolerant of BB/rate-limiting CCB)

22. Amlodipine/Felodipine Starting dose 5mg od; may be increased to 10mg od Lowers BP May cause ankle oedema Nicorandil Starting dose 10mg bd; can be increased to 30mg bd May cause headaches initially Rarely causes mucosal ulceration Antianginal treatment (ctd)

23. Isosorbide Mononitrate (ISMN) Staring dose 30-60mg od; may be increased to 120mg od Shortacting bd preparations less effective May cause headache Long-term use may lead to reduced effect of GTN spray Antianginal treatment (ctd)

24. Ranolazine Starting dose 375mg bd; increase to 500mg bd after 2 weeks Max dose 750mg bd Useful in patients with low BP and/or bradycardia May cause dizziness or nausea; rarely prolongs QT Antianginal treatment (ctd)

25. Ivabradine Starting dose 2.5mg bd; max dose 7.5mg bd Useful when betablockers or rate-limiting CCBs not tolerated or contra-indicated Can be used with betablockers Effective at reducing heart rate; usual target <70bpm at rest Avoid if resting HR <50bpm May cause visual disturbance Antianginal treatment (ctd)

26. Acute chest pain Call 999 12-lead ECG Give Aspirin 300mg od If ECG shows ST Elevation MI, patient is taken directly to Heart Attack Centre for Primary PCI If no ST elevation, taken to local hospital for further assessment

29. Antiplatelet treatment following stents Lifelong aspirin Elective PCI with bare metal stent – 4 weeks clopidogrel Elective PCI with drug eluting stent or bioabsorbablr scaffold – 12 months clopidogrel PCI following NSTEMI or STEMI – 12 months Ticagrelor Ticagrelor -more potent and rapid onset than clopidogrel -also more expensive! -may cause bradycardia and feeling of breathlessness at rest