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Angina.

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slide1

Angina

They who are afflicted with it, are seized while they are walking, (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasiness vanishes.

Heberden W. Some account of a disorder of the breast.

Medical Transactions 2, 59-67 (1772) London: Royal College of Physicians.

causes of angina
myocardial O2 supply

Coronary artery disease

atherosclerosis

spasm

vasculitic disorders

post radiation therapy

Severe anaemia

Causes of Angina

myocardial O2 demand

  • Left ventricular hypertrophy
    • hypertension
    • aortic stenosis
    • aortic regurgitation
    • hypertrophic cardiomyopathy
  • Right ventricular hypertrophy
    • pulmonary hypertension
    • pulmonary stenosis
  • Rapid tachyarrhythmias
slide3

1st diagnosed angina by calendar period and age group

7735 men randomly selected from one GP practice in each of 24 British towns

British Regional Heart Study Lampe, F. C et al. BMJ 2005;330:1046

slide4

Importance of Demographic Changes

  • Aging
  • Female preponderance
  • Obesity
  • Diabetes
slide5

Deaths from cardiovascular disease

Deaths from lung cancer

Deaths from breast cancer

60

Deaths fromcardiovasculardisease

50

40

Deaths frombreast cancer

Percentage of All Deaths

30

20

Deaths fromlung cancer

10

0

>85

0ミ4

5ミ9

75ミ79

10ミ14

15ミ19

20ミ24

25ミ29

30ミ34

35ミ39

40ミ44

45ミ49

50ミ54

55ミ59

60ミ64

65ミ69

70ミ74

80ミ84

Age Group (y)

Demographic Changes: Female Preponderance

Putting therisk of breast cancer in perspective

Note: the proportion of deaths due to breast cancer never exceeds 20%.

Data from Ontario Cancer Registry.

Phillips K-A et al. N Engl J Med. 1999;340:141.

slide6

Indications for Specialist Cardiological Referral

  • New onset angina
  • Exclusion of angina in high risk individuals with atypical symptoms
  • Worsening angina in patient with previously stable symptoms
  • New or recurrent angina in patient with history of:
    • myocardial infarction
    • coronary revascularisation
  • Assessment of occupational fitness (eg airline pilots)
slide7

Diagnosis of Angina

  • History
  • Noninvasive testing
    • Ischaemia
      • ETT
      • Myocardial perfusion imaging
      • Stress echo
    • Disease imaging
      • Calcium imaging (EBCT, MSCT)
  • Angiography
slide8

Diagnosis of Angina

A. History, History, History, History,

  • character
  • location
  • radiation
  • duration
  • provocation
slide9

V4

V5

V6

Rest

3’

exercise

6’

exercise

Peak

exercise

Recovery

Diagnosis of Angina

B. Noninvasive investigation: exercise ECG

Diagnostic features

  • Planar or down-sloping ST depression

Prognostic features

  • Poor exercise tolerance
  • Early ST depression
  • Severe ST depression
  • Exertional arrhythmias
  • Exertional hypotension
slide10

Reversible defects: ischaemia

Exercise

Rest

Fixed defects: infarction

Exercise

Rest

Diagnosis of Angina

B. Noninvasive investigation: isotope perfusion imaging

Diagnostic features

  • Reversible perfusion defects (ischaemia)
  • Fixed perfusion defects (infarction)

Prognostic features

  • extent and severity of perfusion defects (fixed or reversible)
  • degree of lung uptake of radio-isotope (reflecting level of pulmonary capillary pressure)
  • calculated ventricular volume and ejection fraction
slide11

Diagnosis of Angina

C. Arteriography

Invasive

Non-invasive

slide13

baseline

2 years

expected

Angina grade and perceived health status by part

2 of Nottingham Health Profile (NHP) in RITA II

  • work
  • tasksaround home
  • social life
  • home relationships
  • sex life
  • hobbies and interests
  • holidays

Pocock et al Circulation 1996

slide14

Reduce

  • O2 demand
  • heart rate
    • BB
    • procorolan
  • LV wall tension
    • BB
    • Nitrates
    • Nicorandil
    • CaBs
    • ranolazine
  • contractility
    • BB
    • CaBs
  • modify energy metabolism
    • trimetazidine
  • Increase
  • O2 delivery
  • Coronary flow
    • Nitrates
    • CaBs
    • Nicorandil
    • Revasc

Angina: symptom relief with drugs

slide15

Angina: 2° prevention

  • aspirin → all patients
  • statins → all patients - to target 4 and 2 (?)
  • ACE-I → all patients (?)
  • clopidogrel → all patients after PCI or if intolerant of aspirin
slide16

Coronary revascularisation: PCI

Before stenting

After stenting

slide19

PTCA vs medical: meta-analysis

Cardiac death or myocardial infarction

Katritsis, D. G. et al. Circulation 2005;111:2906-2912

slide20

Choice of revasc procedure: considerations

  • Coronary anatomy
  • Patient choice
  • Procedural risk: death, stroke, AMI
  • Symptomatic benefit
  • Repeat revascularisation
  • Prognostic benefit
slide21

Risk-based management strategy in angina

High risk of coronary artery disease

>80%

Intermediate risk of coronary artery disease

20-80%

Low risk of coronary artery disease

<20%

eg: typical angina in men >40 or women >60 years

all other patients with typical or atypical angina

eg: atypical angina in men <30 or women <50 years

Non-invasive ischaemia testing

eg exercise ECG, myocardial perfusion imaging

Anti-anginal drug therapy. In selected cases cardiac catheterization with a view to coronary revascularization

Rule out non-cardiac causes of chest pain before undertaking further cardiac investigation

slide24

Different faces of chronic angina Women - prognosis equal to men

Nitrate angina (n>90,000)

Test +ve angina (n>27,000)

Hemingway et al JAMA 2006

slide26

Isotopeperfusion imaging

Reversible defects: ischaemia

Exercise

Rest

Fixed defects: infarction

Exercise

Rest

Diagnosis of Angina

B. Noninvasive investigation

Exercise ECG