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MANAGEMENT OF Stable angina- The basics

Dr Jayachandran Thejus. MANAGEMENT OF Stable angina- The basics. Coronary artery disease- Block in coronary artery due to plaque or thrombus Leads to myocardial ischemia manifested as chest discomfort Two types- Plaque- stable angina Thrombus- acute coronary syndrome. Stable angina-

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MANAGEMENT OF Stable angina- The basics

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  1. Dr JayachandranThejus MANAGEMENT OF Stable angina- The basics

  2. Coronary artery disease- • Block in coronary artery due to plaque or thrombus • Leads to myocardial ischemia manifested as chest discomfort • Two types- • Plaque- stable angina • Thrombus- acute coronary syndrome

  3. Stable angina- • Obstructive plaque • Blood flow enough at rest • Blood flow is inadequate when heart muscle needs extra blood as during exercise or emotional stress • Angina on exertion or emotion

  4. Stable angina means exertional chest discomfort due to a fixed stenosis in a coronary artery.

  5. How to diagnose whether a person with chest discomfort has coronary artery disease or not? • Assess the probability • Typical nature of pain • Age • Male sex • Risk factors • Low probability- no tests • Intermediate probability- TMT or alternate tests • High probability- coronary angiography

  6. Intermediate probability- which test to choose? • Treadmill exercise test or TMT

  7. TMT is not possible • Pt cannot exercise • LBBB, WPW, pacemaker, resting ST depression, digitalis • SPECT • CT angiography

  8. SPECT • Radioactive technitium is injected IV at stress and at rest • Radioactivity from various areas of the heart is measured. • Perfusion defect during stress indicates ischemic myocardium. • Can be done with adenosine IV in patients who cannot exercise

  9. CT coronary angiography • Negative predictive value is high. • Positive predictive value is low. • Useful to rule out CAD in low risk patients. • If positive, does not mean that stenosis is present. ICA is needed.

  10. Invasive coronary angiography- • Intermediate probability- Stress test positive • High probability • Typical angina • RWMA by echo • Low EF by echo

  11. Patient presents with chest pain. • You evaluate the patient and find the probability of having CAD. • Low probability- follow-up. • Intermediate probability- TMT. If positive- angiography. • High probability- angiography

  12. Angiography- • No plaques- no treatment • Non-obstructive coronary plaques- medical management • Obstructive coronary plaques- • Small vessel- Medical management • Large vessel- PCI or CABG

  13. Coronary stenosis- • Single vessel- PCI • Multivessel- SYNTAX score • <22- PCI • 22 to 32- PCI or CABG • >/= 33-CABG • Left main- • Ostial or mid- PCI • Distal- CABG

  14. Lifestyle modification • Smoking cessation • Most effective lifestyle change • Nicotine gum and bupropion can be given • Diet • Decrease saturated fatty acids • Increase PUFA- fish • Increase fruit and vegetable intake • Decrease total energy intake to keep BMI < 25

  15. Regular physical activity • Aerobic activity like walking is preferred • Intensity depends on cardiac status • Sexual activity • PDE5 inhibitor has interaction with nitrates • Weight reduction • Sleep apnoea evaluation

  16. LDL • Reduce by > 50% • BP • Keep < 140/90 mm Hg

  17. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs

  18. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Aspirin 75 to 150 mg/day. • If intolerant, clopidogrel. • Do not add aspirin to clopidogrel.

  19. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Statin always needs to be added. • LDL has to be reduced by more than 50% of basline value.

  20. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • ACEI to improve prognosis in • HT • DM • CKD • EF 40% or less

  21. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs Sublingual nitrate SOS • 5 mg ISDN • 0.5 mg NTG

  22. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Beta-blocker • Any cardioselective beta-blocker • Do not combine with non-DHP Ca CB • Include to improve prognosis in post MI and HF.

  23. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • CaCB • Non-DHP • Verapamil • Diltiazem • DHP • Long acting nifedipine • Amlodipine

  24. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Long acting nitrate • If frequent angina • 10 mg ISDN TDS or 30 – 60 mg ISMN bid or controlled release NTG 2.6 or 6.4 mg bid • Try to avoid CaCB or alpha blocker

  25. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Ranolazine • 500 to 1000 mg bid • Most trial data among alternative drugs • No effect on BP or heart rate

  26. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Ivabradine • 5 to 7.5 mg bid • If rate is uncontrolled even after b B optimum dose

  27. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Nicorandil • 5 to 10 mg bid

  28. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • Trimetazidine • 35 mg bid

  29. Pharmacological treatment- • To improve long term prognosis • Aspirin • Statin • To relieve angina • S/L nitrate SOS • If angina is frequent- b B or Ca CB or both • Is still no relief- long acting nitrate or other drugs • EECP • Spinal cord stimulation • Chelation

  30. You can download the slide set at heartpearls.com Thank you

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