Download ANGINA PECTORIS Classic angina is characterized by substernal

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.
ANGINA
STABLE ANGINA
CLASSIFICATION
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Exertional.
Variant.
Anginal Equivalent Syndrome.
Prinzmetal’s Angina.
Syndrome-X.
Silent Ischemia.
ANGINA: EXERTIONAL
• Coronary artery obstructions are not sufficient to
result in resting myocardial ischemia. However,
when myocardial demand increases, ischemia
results.
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
• Patient’s with exertional dyspnea rather than
exertional chest pain.
• Caused by exercise induced left ventricular
dysfunction.
ANGINA: PRINZMETAL’S
ANGINA
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Spasm of a large coronary artery.
Transmural ischemia.
ST-Segment elevation at rest or with exercise.
Not very common.
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
• Very common.
• More episodes of silent than painful ischemia in the
same patient.
• Difficult to diagnose.
• Holter monitor.
• Exercise testing.
ANGINA: TREATMENT GOALS
• Feel better.
• Live longer.
ANGINA: PROGNOSIS
• Left ventricular function.
• Number of coronary arteries with significant
stenosis.
• Extent of jeoporized myocardium.
STABLE ANGINA
Risk stratification.
• Noninvasive testing.
• Cardiac catheterization.
STABLE ANGINA
EVALUATION OF LV FUNCTION
• Physical exam.
• CXR.
• Echocardiogram.
STABLE ANGINA
EVALUATION OF ISCHEMIA
• History.
• Baseline Electrocardiogram.
• Exercise Testing.
CCS 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.
STABLE ANGINA
EXERCISE TESTING
• The goal of exercise testing is to induce a
controlled, temporary ischemic state during clinical
and ECG observation.
ANGINA: EXERCISE TESTING
ANGINA: EXERCISE TESTING
HIGH 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.
ECG TREADMILL TEST 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 TEST
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Diagnosis/prognosis for CAD.
Non-diagnostic TEST.
Abnormal resting ECG.
Negative TEST with continued chest pain.
Intermediate probability of disease.
STABLE ANGINA
GUIDELINES FOR NUCLEAR TEST
Defined CAD.
• Post infarct risk stratification.
• Risk stratification to determine need for
revascularization ( viability study ).
STABLE ANGINA
DIPYRIDAMOLE NUCLEAR TEST
• Near equivalent sensitivity/specificity with
symptom-limited nuclear TEST.
• Most useful in patients who cannot exercise.
• Major contraindication is severe bronchospastic
lung disease ( consider Dobutamine study ).
STABLE ANGINA
STRESS ECHO
• Ischemia may cause wall motion abnormalities, no
rise of fall in LVEF.
• Sensitivity/specificity same as nuclear testing.
• May be better in women.
STRESS ECHO VS. NUCLEAR
STRESS
EXERCISE TESTING
CONTRAINDICATIONS
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MI—impending or acute.
Unstable angina.
Acute myocarditis / pericarditis.
Acute systemic illness.
Severe aortic stenosis.
Congestive heart failure.
Severe hypertension.
Uncontrolled cardiac arrhythmias.
STABLE ANGINA
NON-INVASIVE EVALUATION
Non disabling Angina
Resting LV Functions
LV dysfunction
Coronary Angiography
Normal LV function
Stress Test
High Risk
Coronary Angiography
Low Risk
Medical Therapy
Stable
Medical Therapy
Recurrent Angina
Coronary Angiography
CARDIAC CATHETERIZATION
INDICATIONS
• 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
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Hypertension
Smoking
Dyslipidemia
Diabetes Mellitus
Obesity
Stress
Homocysteine
STABLE ANGINA
TREATMENT OPTIONS
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Treatment Option
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Percutaneous
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Intervention
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STABLE ANGINA MEDICAL TREATMENT
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Beta-blockers
Calcium channel blockers
Nitrates
Aspirin
Statins
? ACE inhibitors
STABLE ANGINA
CONSIDERATIONS WHEN CHOOSING A DRUG
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Effect on myocardium
Effect on cardiac conduction system
Effect on coronary/systemic arteries
Effect on venous capitance system
Circadian rhytm
BETA-BLOCKERS
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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
BETA BLOCKERS
SIDE EFFECTS
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Bronchospasm
Diminished exercise capacity
Negative inotropy
Sexual dysfunction
Bradyarrhythmia
Masking of hypoglycemia
Increased claudication
Hair loss
BETA BLOCKERS
COMMON AVAILABLE AGENTS
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Propranolol
Atenolol
Metoprolol
Nadolol
Timolol
CALCIUM CHANNEL BLOCKERS
MECHANISMS OF ACTION
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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
MECHANISMS OF ACTION
CALCIUM CHANNEL BLOCKERS
MECHANISMS OF ACTION
CALCIUM CHANNEL BLOCKERS
SIDE EFFECTS
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Palpitations
Headache
Ankle edema
Gingival hyperplasia
CALCIUM CHANNEL BLOCKERS
AVAILABLE AGENTS
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Verapamil
Diltiazem
Nifedipine
Nicardipine
Amlodipine
Felodipine
Nisoldipine
Bepridil
NITRATES
MECHANISMS OF ACTION
• Nitric oxide has been identified as endotheliumderived relaxing factor
• Organic nitrates are therapeutic precursors of
endothelium-derived relaxing factor
NITRATES
MECHANISMS OF ACTION
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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
• 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
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Headache
Flushing
Palpitations
Tolerance
NITRATES
COMMON AVAILABLE AGENTS
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Isorbide dinitrate
Isorbide mononitrate
Long-acting transdermal patches
Nitroglycerin SL
STABLE ANGINA
TREATMENT OPTIONS
• CABG
• PTCA
STABLE ANGINA: 1-VESSEL CAD
THERAPEUTIC 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
• 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
• 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