Coronary artery disease

• Coronary artery disease (CAD) most common cause of death in Australia. Includes angina, ischaemic heart disease, heart attack
• Consider heart disease in any person with chest pain
• Heart attack or stroke common in people with diabetes
• Quitting smoking is the most important action to lessen risk of heart attack
• Brief interventions
• Nicotine replacement therapy (NRT) and urge reduction medicines can be used
• If severe angina or less than 4 weeks since heart attack — talk with cardiologist about NRT
• Reduce cardiovascular risk across all modifiable risk factors including physical activity and nutrition:
  
• Diabetes
• High BP
• Kidney disease
• Abnormal lipids (blood fats)
• Non-modifiable risk factors
• Family history of heart attack
• After menopause
• Previous cardiovascular events

Ask

• Chest pain
• Where do they get pain, does it spread anywhere
• When did the pain start
• What were they doing when pain started
• Does chest pain happen with activity, or what brings it on
• How often they get chest pain — daily, weekly
• How long does pain last
• How bad is pain — rate out of 10 or use faces scale

• Shortness of breath, ankle swelling
• Palpitations, dizziness, nausea, vomiting
• About risk factors — smoking, physical activity, takeaway and processed foods (saturated fat, sugar, salt)
• Other health problems — diabetes, high BP, family history of heart problems
• Medicines for chest pain — do they stop pain, when does person take them
• Other medicines — are they taking them

Check

• BMI, waist circumference
• ECG if any new symptoms, and routinely at least every 12 months
• Any changes from previous ECG
• Head-to-toe exam — with attention to heart and lung exam

Do

• FBC, UEC, BGL, HbA1c, fasting lipids, TFT, urine ACR
• Cardiovascular risk assessment
• Risk assessment for recurrent chest pain — see Table 4.8
  
• If medium or high risk, or any concerns — medical consult
• If low risk — medical follow-up
• Start immediate management
• Organise referrals as needed
• Give information on tobacco, brief intervention for smoking

Typical angina (chest pain) includes all of

• Central chest discomfort, feels ‘tight’ or ‘pressing’, lasts for minutes
• AND brought on by exertion or emotional stress
• AND relieved by rest or angina medicine

Non-typical chest pain has only 1 or 2 features of ‘typical chest pain’

Based on results of exercise ECG (stress test)

• If CAD possible
• Medical consult
• Refer for urgent specialist review, may need angiogram
• Continue aspirin — 100mg once a day AND angina medicines as needed
• Start beta-blocker if not contraindicated (eg slow heart rate, reversible airways disease, already on calcium channel blocker)
• If chest pain occurs overnight or at rest — use calcium channel blocker not beta-blocker
• Do brief interventions for smoking, healthy diet, physical activity
• If not likely to be CAD
• Consider other causes of chest pain — see Acute assessment of chest pain
• May be able to stop aspirin and angina medicine
• Manage other risk factors
• If chest pain continues — medical consult

Follow-up

• Combined checks for chronic conditions

Medicines for CAD

To reduce risk of heart attack OR if person has ever had a heart attack — medical consult

• Aspirin
• Statin
• ACE inhibitor
• Beta-blocker (eg atenolol oral — 25–100mg once a day )
• Start at 25mg once a day, double dose every 2 weeks up to 100mg
• Can add dihydropyridines calcium channel blocker (eg nifedipine, amlodipine)
• If recurrent angina while on aspirin OR after heart attack or stent 
• Clopidogrel oral — 75mg, once a day for 1 year
• OR ticagrelor oral — 90mg, twice a day (bd) for at least 1 year 
• Specialist advice before temporary or permanent cessation

For chest pain (angina)

• Treatment choices for acute angina pain
• Glyceryl trinitrate 1 spray under tongue — 400microgram
• OR Isosorbide dinitrate 1 tablet under tongue — 5mg
• Write date bottle opened on label, replace 3 months later
• Management choices for chronic angina — medical consult
  
• Isosorbide mononitrate
• Nitrate patch
• Nicorandil
• Ivabradine

Advice for using angina medicines at home

• If chest pain worse than usual — treat as a heart attack. Get help straight away
• Do not take more than 1 dose of medication at a time (can make BP too low)
• Do not use nitrate therapy if drugs for impotence used recently
• Sildenafil or vardenafil in past 24 hours
• Tadalafil in past 2 days
• Always carry medicine for acute angina pain with you
• Keep it cool and air tight
• Keep glyceryl trinitrate spray out of the light
• When angina heart pain starts
• Sit or lie down before taking medicine
• Take 1 dose of medicine for acute angina pain — expect a headache, dizziness
• If still chest pain or discomfort after 5 minutes — take another dose
• If still pain after another 10 minutes (total of 15 minutes) — take another dose, call ambulance or go straight to clinic or hospital
• If still pain in another 15 minutes (total of 30 minutes) — can take another dose