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Management of Stable Angina Pectoris

Management of Stable Angina Pectoris. Bushra Abdul Hadi. Angina Pectoris. Classic angina is characterized by substernal squeezing chest pain, occurring with stress and relieved with rest or nitroglycerin. May radiate down the left arm

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Management of Stable Angina Pectoris

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  1. Management ofStable Angina Pectoris Bushra Abdul Hadi

  2. Angina Pectoris • Classic angina is characterized by substernal squeezing chest pain, occurring with stress and relieved with rest or nitroglycerin. • May radiate down the left arm • May be associated with nausea, vomiting, or diaphoresis.

  3. Angina

  4. Stable AnginaClassification • Exertional • Variant • Anginal Equivalent Syndrome • Prinzmetal’s Angina • Syndrome-X • Silent Ischemia

  5. Angina: Exertional • Coronary artery obstructions are not sufficient to result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results.

  6. Angina: Variant Angina • Transient impairment of coronary blood supply by vasospasm or platelet aggregation • Majority of patients have an atherosclerotic plaque • Generalized arterial hypersensitivity • Long term prognosis very good

  7. Angina: Anginal Equivalent Syndrome • Patient’s with exertional dyspnea rather than exertional chest pain • Caused by exercise induced left ventricular dysfunction

  8. Angina: Prinzmetal’s Angina • Spasm of a large coronary artery • Transmural ischemia • ST-Segment elevation at rest or with exercise • Not very common

  9. Angina: Syndrome X • Typical, exertional angina with positive exercise stress test • Anatomically normal coronary arteries • Reduced capacity of vasodilation in microvasculature • Long term prognosis very good • Calcium channel blockers and beta blockers effective

  10. Angina: Silent Ischemia • Very common • More episodes of silent than painful ischemia in the same patient • Difficult to diagnose • Holter monitor • Exercise testing

  11. Angina: Treatment Goals • Feel better • Live longer

  12. Angina: Prognosis • Left ventricular function • Number of coronary arteries with significant stenosis • Extent of jeoporized myocardium

  13. Stable Angina Risk stratification • Noninvasive testing • Cardiac catheterization

  14. Stable AnginaEvaluation of LV Function • Physical exam • CXR • Echocardiogram

  15. Stable AnginaEvaluation of Ischemia • History • Baseline Electrocardiogram • Exercise Testing

  16. Class I Class II Class III Class IV Angina only with extreme exertion Angina with walking 1 to 2 blocks Angina with walking 1 block Angina with minimal activity CCSC Angina Classification

  17. Stable AnginaExercise Testing • The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation

  18. Angina: Exercise Testing

  19. Angina: Exercise TestingHigh Risk Patients • Significant ST-segment depression at low levels of exercise and/or heart rate<130 • Fall in systolic blood pressure • Diminished exercise capacity • Complex ventricular ectopy at low level of exercise

  20. Angina: Exercise TestingLow Risk Group CASS Registry: 7 year survival • Less than 1 mm ST depression in Stage III of Bruce Protocol • Annual mortality: 1.3% JACC 1986;8:741-8

  21. ECG Treadmill EST in Women • Higher false-positive rate • Reduces procedures without loss of diagnostic accuracy • Only 30% of women need be referred for further testing

  22. Stable AnginaGuidelines for Nuclear EST Diagnosis/prognosis for CAD • Non-diagnostic EST • Abnormal resting ECG • Negative EST with continued chest pain • Intermediate probability of disease

  23. Stable AnginaGuidelines for Nuclear EST Defined CAD • Post infarct risk stratification • Risk stratification to determine need for revascularization ( viability study )

  24. Stable AnginaDipyridamole Nuclear EST • Near equivalent sensitivity/specificity with symptom-limited nuclear EST • Most useful in patients who cannot exercise • Major contraindication is severe bronchospastic lung disease ( consider Dobutamine study )

  25. Appropriateness of Radionuclide Exercise Testing • Retrospective analysis of 1092 patients • 64% of tests ordered by cardiologists were indicated • 30% of tests ordered by non-cardiologists were indicated • Excessive charges from non-indicates tests were $1,082,400 Am J Card 1996;77:139-42

  26. Stable AnginaStress Echo • Ischemia may cause wall motion abnormalities, no rise of fall in LVEF • Sensitivity/specificity same as nuclear testing • May be better in women

  27. Stress Echo vs. Nuclear Stress

  28. Exercise TestingContraindications • MI—impending or acute • Unstable angina • Acute myocarditis/pericarditis • Acute systemic illness • Severe aortic stenosis • Congestive heart failure • Severe hypertension • Uncontrolled cardiac arrhythmias

  29. Stable AnginaNon-Invasive Evaluation

  30. Cardiac CatheterizationIndications • Suspicion of multi-vessel CAD • Determine if CABG/PTCA feasible • Rule out CAD in patients with persistent/disabling chest pain and equivocal/normal noninvasive testing

  31. Risk Factor Modification • Hypertension • Smoking • Dyslipidemia • Diabetes Mellitus • Obesity • Stress • Homocysteine

  32. Stable AnginaTreatment Options

  33. Stable AnginaTreatment Options • Medical Treatment

  34. Stable AnginaCurrent Pharmacotherapy • Beta-blockers • Calcium channel blockers • Nitrates • Aspirin • Statins • ? ACE inhibitors

  35. Stable AnginaConsiderations when Choosing a Drug • Effect on myocardium • Effect on cardiac conduction system • Effect on coronary/systemic arteries • Effect on venous capitance system • Circadian rhytm

  36. Beta-Blockers • Decrease myocardial oxygen consumption • Blunt exercise response • Beta-one drugs have theoretical advantage • Try to avoid drugs with intrinsic sympathomimetic activity • First line therapy in all patients with angina if possible

  37. Beta-Blockers

  38. Beta BlockersSide Effects • Bronchospasm • Diminished exercise capacity • Negative inotropy • Sexual dysfunction • Bradyarrhythmia • Masking of hypoglycemia • Increased claudication • Hair loss

  39. Beta BlockersCommon Available Agents • Propranolol • Atenolol • Metoprolol • Nadolol • Timolol

  40. Calcium Channel BlockersMechanisms of Action • Arterial dilation/after-load reduction • Coronary arterial vasodilation • Prevention of coronary vasoconstriction • Enhancement of coronary collateral flow • Improved subendocardial perfusion • Slowing of heart rate with diltiazem, verapamil

  41. Calcium Channel BlockersMechanisms of Action

  42. Calcium Channel BlockersMechanisms of Action

  43. Calcium Channel BlockersSide Effects • Palpitations • Headache • Ankle edema • Gingival hyperplasia

  44. Calcium Channel BlockersAvailable Agents • Verapamil • Diltiazem • Nifedipine • Nicardipine • Amlodipine • Felodipine • Nisoldipine • Bepridil

  45. Stable AnginaTreatment Options

  46. NitratesMechanisms of Action • Nitric oxide has been identified as endothelium-derived relaxing factor • Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

  47. NitratesMechanisms of Action • Venous vasodilation/pre-load reduction • Arterial dilation/after-load reduction • Coronary arterial vasodilation • Prevention of coronary vasoconstriction • Enhancement of coronary collateral flow • Antiplatelet and antithrombotic effects

  48. NitratesReducing Tolerance • Smaller doses • Less frequent dosing • Avoidance of long-acting formulations unless a prolonged nitrate-free interval is provided • Build-in a nitrate-free interval o 8-12 hours

  49. NitratesSide Effects • Headache • Flushing • Palpitations • Tolerance

  50. To provide optimal benefit to patients, clinicians must use nitroglycerin more systematically and critically than they have before W. Frischman

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