Download Guideline for stable angina

Guideline for stable angina
CAD and IHD
•Coronary artery disease (CAD):
• Atherosclerosis is a complex inflammatory, fibroproliferative response
•Ischemic heart disease (IHD):
•Myocardial oxygen demand exceeds the capacity of coronary artery to deliver an
adequate supply of oxygen
Clinical classification of chest pain
•Typical angina(definite)
• (1)Substernal chest discomfort with characteristic quality and duration
(2)provoked by exertion or emotional stress
(3)relieved by rest or nitroglycerin
•Atypical angina(probable)
• meets 2 of the above characteristics
•Noncardiac chest pain
• meets £ 1 of the typical angina characteristics
Risk factors for CAD
•Age(male>45 y/o, female>55 y/o)
•Male
•Smoking
•LDL-cholestrol
•Hypertension
•Diabetic mellitus
•Family history of CAD
•Hyperhomocysteinemia
•Obesity
•Inactive lifestyle
Diagnosis
EKG manifestation of stable angina
•Resting EKG:
• normal in half of patients with chronic stable angina
• nonspecific ST-T change with/without abnormal Q wave,or ST elevation during
episodes of angina pectoris
•>50% of patients with normal EKG became abnormal during episodes of angina
pectoris
Treadmill test
1.Indication
in diagnosis of obstructive CAD(adult patients with intermediate pretest probability of
CAD)
risk assessment and prognosis in patients with symptoms or previous history of CAD
after AMI, prognostic assessment
before and after revascularization
investigation of heart rhythm
exercise test with ventilatory gas analysis
2.Contraindication (absolute)
AMI(within 2 days)
unstable angina not previous stabilized by medical therapy
uncontrolled cardiac arrhythmia causing symptomatic hemodynamic change
symptomatic severe aortic stenosis
uncontrolled symptomatic heart failure
acute pulmonary embolism or pulmonary infarction
acute myocarditis or pericarditis
acute aortic dissection
3.Contraindication(relative)
left main coronary disease
moderate stenotic valvular heart disease
electrolyte abnormality
severe arterial hypertension
tachyarrhythmia or bradyarrhythmia
hypertrophic cardiomyopathy and other forms of outflow tract
metal or physical impairment leading to inability to exercise adequately
high degree AV block
4.Sensitivity:68% ,specificity: 77%
Myocardial perfusion scan
(persantin thallium scan)
1.Indication
evaluation of chest pain syndrome for presence of CAD
evaluation of known stenotic lesion at angiography
evaluation of patient after an AMI
evaluation of patient after angioplasty or coronary bypass graft
pre-op evaluation of patients with high risk of CAD
evaluation of myocardium vaibility
2.Contraindication
history of asthma or severe COPD requiring high doses of theophylline
severe bradycardia or high degree AV block without protection of pacemaker
implantation
unstable angina
recent MI
patient cannot cooperate
Dobutamine stress echocardiography
1.Indication
Evaluate patients with symptoms suggestive of CAD
Evaluate pateints with known CAD
Risk stratify patient before noncardiac surgery ,after myocardial infarction , or
interventional procedures and prior to starting an exercise program
Ambiguous stress EKG examination
To evaluate left ventricular global and segmental systolic function
To identify viable ,hibernating ,or stunned myocardium
To evaluate hemodynamics in valvular /cardiomyopathic heart disease
2.Absolute contraindication
AMI(within 2 days)
Unstable angina
Uncontrolled cardiac rhythm
Symptomatic valvular aortic stenosis(mean resting gradient >50 mmHg)
Acute pulmonary embolism or pulmonary infarction
Acute myocarditis or pericarditis
Acute aortic dissection
pregnancy
Coronary angiography
1.Indication
Inadequate control of symptoms with optimal medical therapy
Patient at high risk as determined with stress testing
Evidence of moderate LV dysfunction
Preparation for major vascular operation
Occupation or lifestyle that involves unusual risk(such as pilot)
2. No absolute contraindication
3. Relative contraindication
unexplained fever
untreated infection
severe anemia (Hb < 8 g/dl)
severe electrolyte imbalance
digitalis intoxication
previous contrast allergy
severe coagulopathy
active infective endocarditis
acute renal failure
TREATMENT
Medication for stable angina
1.Platelet inhibitor
A.aspirin
B.ticlopidine or clopidogrel if allergy to or intolerance to aspirin
side effect of ticlopidine : neutropenia,thrombocytopenia, pancytopenia
2.Lipid- lowering agent
in primary and secondary prevention of CAD
to lower LDL-C level to 100md/dL among patients with known CAD
to measure liver enzyme and creatine kinase 6 weeks after lipid lowering agent
3.Nitrate
reducing preload and afterload of left ventricle
NTG can be used when activities known to precipitate angina are anticipated
Side effect:headache, flushing, dizziness, weakness, postural hypotension
Interaction :sildenfil and nitrates can lead to severe hypotension
4.Beta blocker
decreased rate -pressure product and oxygen demand, symptomatic improvement
Avoid among patients with known coronary spasm
Side effect:bronchoconstriction, masking of hypoglycemic reaction, depression,
bradycardia, precipitation of heart failure,libido, alter lipid profile(HDL ,LDL)
Interaction:severe bradycardia and hypotension occurred with concomitant use of
calcium blocker
5.Calcium channel blocker(diltiazem and verapamil)
decrease angina attack, decreased rate -pressure product and oxygen demand
side effect:hypotension, flushing, dizziness, headache, impaired LV function,
bradycardia
interaction: digitalis level are increased by calcium channel blocker
CABG
Significant left main coronary disease
3 -vessel disease.The survival benefit is greater in patients with abnormal LV
function(EF less than 50%)
2- vessel disease with significant proximal left anterior descending CAD and either
abnormal LV function (EF less than 50%), or demonstrable ischemia on noninvasive
testing
Patients with 1- or 2 -vessel CAD without significant proximal left anterior
descending CAD but with a large area of viable myocardium and high-risk criteria on
noninvasive testing
For recurrent stenosis associated with large area of viable myocardium and /or high
risk criteria on noninvasive testing
PCI
Patients with 2- or 3- vessel disease with significant proximal left anterior descending
CAD ,who have anatomy suitable for catheter based therapy,normal LV function and
who do not have treated diabetes
Patients with 1- or 2 -vessel CAD without significant proximal left anterior
descending CAD but with a large area of viable myocardium and high-risk criteria on
noninvasive testing
For recurrent stenosis associated with large area of viable myocardium and /or high
risk criteria on noninvasive testing
Unstable angina
Recent onset of effort angina
Effort angina with changing pattern i.e. increased frequency or duration
Resting angina
Braunwald Classification of unstable angina
CCS classification of unstable angina
Risk stratification of patients with unstable angina
1.High risk
One of the following must be present:
 prolonged ongoing rest pain(>20 mins): moderate or high likelihood of CAD
 pulmonary edema:most likely caused by ischemia
 rest angina with dynamic ST change 1mm
Angina with new or worsening rales ,S3,or MR murmur
Angina with hypotension
No high risk feature but must have one of following:





Prolonged rest pain (>20 min) that resolves
Rest angina(>20 min or relieved with rest or sublingual NTG)
Nocturnal angina
Angina with dynamic T waves changes
New onset ,severe angina within 2 weeks with moderate or high likelihood of
CAD
 Pathological Q waves or resting ST depression in multiple lead groups
age older than 65 years
2.Low risk
no high or intermediate risk features present
increased frequency or duration of angina
angina provoked by less exertion
new-onset angina(within 2 weeks- 2 months)
normal or unchange ECG
Reference
1. Management of patients with chronic stable angina. ACC/AHA 2003 pocket
guideline
2.Roberto AO. et al. Diagnosis and management of patients with chronic ischemic
heart disease.Hurst’s “THE HEART” 10th ed. MaGraw-Hill Co;2001:1207-1236
3. Bernald JG. et al. Chronic coronary artery disease. Braunwald “Heart disease” 6th
ed. W.B. Saunder ;Co.2001:1272-1352
4.Nuclear cardiology.Cardiology clinic.May 1994;12:2