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
  • Reduce cardiovascular risk across all modifiable risk factors including physical activity and nutrition:
  • 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

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • 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’

Table 4.8 Risk assessment and actions for recurrent 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

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