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Management of Stable Angina Pectoris. David Putnam, MD Albany Medical College. 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

Management ofStable Angina Pectoris

David Putnam, MD

Albany Medical College

angina pectoris
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.
stable angina classification
Stable AnginaClassification
  • Exertional
  • Variant
  • Anginal Equivalent Syndrome
  • Prinzmetal’s Angina
  • Syndrome-X
  • Silent Ischemia
angina exertional
Angina: Exertional
  • Coronary artery obstructions are not sufficient to result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results.
angina variant angina
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
angina anginal equivalent syndrome
Angina: Anginal Equivalent Syndrome
  • Patient’s with exertional dyspnea rather than exertional chest pain
  • Caused by exercise induced left ventricular dysfunction
angina prinzmetal s angina
Angina: Prinzmetal’s Angina
  • Spasm of a large coronary artery
  • Transmural ischemia
  • ST-Segment elevation at rest or with exercise
  • Not very common
angina syndrome x
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
angina silent ischemia
Angina: Silent Ischemia
  • Very common
  • More episodes of silent than painful ischemia in the same patient
  • Difficult to diagnose
  • Holter monitor
  • Exercise testing
angina treatment goals
Angina: Treatment Goals
  • Feel better
  • Live longer
angina prognosis
Angina: Prognosis
  • Left ventricular function
  • Number of coronary arteries with significant stenosis
  • Extent of jeoporized myocardium
stable angina
Stable Angina

Risk stratification

  • Noninvasive testing
  • Cardiac catheterization
stable angina evaluation of lv function
Stable AnginaEvaluation of LV Function
  • Physical exam
  • CXR
  • Echocardiogram
stable angina evaluation of ischemia
Stable AnginaEvaluation of Ischemia
  • History
  • Baseline Electrocardiogram
  • Exercise Testing
ccsc angina classification
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
stable angina exercise testing
Stable AnginaExercise Testing
  • The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation
angina exercise testing high risk patients
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
angina exercise testing low risk group
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

ecg treadmill est in women
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
stable angina guidelines for nuclear est
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
stable angina guidelines for nuclear est21
Stable AnginaGuidelines for Nuclear EST

Defined CAD

  • Post infarct risk stratification
  • Risk stratification to determine need for

revascularization ( viability study )

stable angina dipyridamole nuclear est
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 )
appropriateness of radionuclide exercise testing
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

stable angina stress echo
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
exercise testing contraindications
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
cardiac catheterization indications
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
risk factor modification
Risk Factor Modification
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Diabetes Mellitus
  • Obesity
  • Stress
  • Homocysteine
stable angina current pharmacotherapy
Stable AnginaCurrent Pharmacotherapy
  • Beta-blockers
  • Calcium channel blockers
  • Nitrates
  • Aspirin
  • Statins
  • ? ACE inhibitors
stable angina considerations when choosing a drug
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
beta blockers
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
beta blockers side effects
Beta BlockersSide Effects
  • Bronchospasm
  • Diminished exercise capacity
  • Negative inotropy
  • Sexual dysfunction
  • Bradyarrhythmia
  • Masking of hypoglycemia
  • Increased claudication
  • Hair loss
beta blockers common available agents
Beta BlockersCommon Available Agents
  • Propranolol
  • Atenolol
  • Metoprolol
  • Nadolol
  • Timolol
calcium channel blockers mechanisms of action
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
calcium channel blockers side effects
Calcium Channel BlockersSide Effects
  • Palpitations
  • Headache
  • Ankle edema
  • Gingival hyperplasia
calcium channel blockers available agents
Calcium Channel BlockersAvailable Agents
  • Verapamil
  • Diltiazem
  • Nifedipine
  • Nicardipine
  • Amlodipine
  • Felodipine
  • Nisoldipine
  • Bepridil
nitrates mechanisms of action
NitratesMechanisms of Action
  • Nitric oxide has been identified as endothelium-derived relaxing factor
  • Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor
nitrates mechanisms of action43
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
nitrates reducing tolerance
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
nitrates side effects
NitratesSide Effects
  • Headache
  • Flushing
  • Palpitations
  • Tolerance
slide46
To provide optimal benefit to patients, clinicians must use nitroglycerin more systematically and critically than they have before

W. Frischman

nitrates common available agents
NitratesCommon Available Agents
  • Isorbide dinitrate
  • Isorbide mononitrate
  • Long-acting transdermal patches
  • Nitroglycerin sl
stable angina 1 vessel cad therapeutic strategies
Stable Angina: 1-Vessel CADTherapeutic Strategies
  • Initiate pharmacologic treatment

A. Nearly half of patients will become asymptomatic

  • PTCA preferred alternative if medical therapy does not relieve angina or causes adverse effects
stable angina 2 vessel cad therapeutic strategies
Stable Angina: 2-Vessel CADTherapeutic Strategies
  • Initial medical management in patients with mild ischemic symptoms and normal LV function
  • Revascularization in patients who fail medical therapy
  • Selection of PTCA vs. CABG depends on coronary anatomy, LV function, need for complete revascularization, and patient preference
stable angina 3 vessel cad therapeutic strategies
Stable Angina: 3-Vessel CADTherapeutic Strategies
  • CABG in patients with left-main disease or 3-vessel CAD and decreased LVEF
  • PTCA or medical management an alternative in patients with 3-vessel CAD, mild symptoms, and preserved LVEF