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Management of Stable Angina Pectoris

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of Stable Angina Pectoris Bushra Abdul Hadi Angina Pectoris Classic angina is characterized by substernal squeezing chest pain, occurring with stress and relieved ... – PowerPoint PPT presentation

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Title: Management of Stable Angina Pectoris


1
Management of Stable Angina Pectoris
  • Bushra Abdul Hadi

2
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.

3
Angina
4
Stable Angina Classification
  • Exertional
  • Variant
  • Anginal Equivalent Syndrome
  • Prinzmetals Angina
  • Syndrome-X
  • Silent Ischemia

5
Angina Exertional
  • Coronary artery obstructions are not sufficient
    to result in resting myocardial ischemia.
    However, when myocardial demand increases,
    ischemia results.

6
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

7
Angina Anginal Equivalent Syndrome
  • Patients with exertional dyspnea rather than
    exertional chest pain
  • Caused by exercise induced left ventricular
    dysfunction

8
Angina Prinzmetals Angina
  • Spasm of a large coronary artery
  • Transmural ischemia
  • ST-Segment elevation at rest or with exercise
  • Not very common

9
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

10
Angina Silent Ischemia
  • Very common
  • More episodes of silent than painful ischemia in
    the same patient
  • Difficult to diagnose
  • Holter monitor
  • Exercise testing

11
Angina Treatment Goals
  • Feel better
  • Live longer

12
Angina Prognosis
  • Left ventricular function
  • Number of coronary arteries with significant
    stenosis
  • Extent of jeoporized myocardium

13
Stable Angina
  • Risk stratification
  • Noninvasive testing
  • Cardiac catheterization

14
Stable Angina Evaluation of LV Function
  • Physical exam
  • CXR
  • Echocardiogram

15
Stable Angina Evaluation of Ischemia
  • History
  • Baseline Electrocardiogram
  • Exercise Testing

16
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

17
Stable Angina Exercise Testing
  • The goal of exercise testing is to induce a
    controlled, temporary ischemic state during
    clinical and ECG observation

18
Angina Exercise Testing
19
Angina Exercise Testing High Risk Patients
  • Significant ST-segment depression at low levels
    of exercise and/or heart ratelt130
  • Fall in systolic blood pressure
  • Diminished exercise capacity
  • Complex ventricular ectopy at low level of
    exercise

20
Angina Exercise Testing Low Risk Group
  • CASS Registry 7 year survival
  • Less than 1 mm ST depression in Stage III of
    Bruce Protocol
  • Annual mortality 1.3
  • JACC 19868741-8

21
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

22
Stable Angina Guidelines for Nuclear EST
  • Diagnosis/prognosis for CAD
  • Non-diagnostic EST
  • Abnormal resting ECG
  • Negative EST with continued chest pain
  • Intermediate probability of disease

23
Stable Angina Guidelines for Nuclear EST
  • Defined CAD
  • Post infarct risk stratification
  • Risk stratification to determine need for
  • revascularization ( viability study )

24
Stable Angina Dipyridamole 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 )

25
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 199677139-42

26
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

27
Stress Echo vs. Nuclear Stress
28
Exercise Testing Contraindications
  • MIimpending or acute
  • Unstable angina
  • Acute myocarditis/pericarditis
  • Acute systemic illness
  • Severe aortic stenosis
  • Congestive heart failure
  • Severe hypertension
  • Uncontrolled cardiac arrhythmias

29
Stable Angina Non-Invasive Evaluation
30
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

31
Risk Factor Modification
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Diabetes Mellitus
  • Obesity
  • Stress
  • Homocysteine

32
Stable Angina Treatment Options
33
Stable Angina Treatment Options
  • Medical Treatment

34
Stable Angina Current Pharmacotherapy
  • Beta-blockers
  • Calcium channel blockers
  • Nitrates
  • Aspirin
  • Statins
  • ? ACE inhibitors

35
Stable Angina Considerations when Choosing a Drug
  • Effect on myocardium
  • Effect on cardiac conduction system
  • Effect on coronary/systemic arteries
  • Effect on venous capitance system
  • Circadian rhytm

36
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

37
Beta-Blockers
38
Beta Blockers Side Effects
  • Bronchospasm
  • Diminished exercise capacity
  • Negative inotropy
  • Sexual dysfunction
  • Bradyarrhythmia
  • Masking of hypoglycemia
  • Increased claudication
  • Hair loss

39
Beta Blockers Common Available Agents
  • Propranolol
  • Atenolol
  • Metoprolol
  • Nadolol
  • Timolol

40
Calcium Channel Blockers Mechanisms 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

41
Calcium Channel Blockers Mechanisms of Action
42
Calcium Channel Blockers Mechanisms of Action
43
Calcium Channel Blockers Side Effects
  • Palpitations
  • Headache
  • Ankle edema
  • Gingival hyperplasia

44
Calcium Channel Blockers Available Agents
  • Verapamil
  • Diltiazem
  • Nifedipine
  • Nicardipine
  • Amlodipine
  • Felodipine
  • Nisoldipine
  • Bepridil

45
Stable Angina Treatment Options
46
Nitrates Mechanisms of Action
  • Nitric oxide has been identified as
    endothelium-derived relaxing factor
  • Organic nitrates are therapeutic precursors of
    endothelium-derived relaxing factor

47
Nitrates Mechanisms 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

48
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

49
Nitrates Side Effects
  • Headache
  • Flushing
  • Palpitations
  • Tolerance

50
  • To provide optimal benefit to patients,
    clinicians must use nitroglycerin more
    systematically and critically than they have
    before
  • W. Frischman

51
Nitrates Common Available Agents
  • Isorbide dinitrate
  • Isorbide mononitrate
  • Long-acting transdermal patches
  • Nitroglycerin sl

52
Stable Angina Treatment Options
  • CABG

53
Stable Angina Results of CABG
  • 65 remain symptom-free at ten years
  • 85 remain free of fatal/nonfatal MI at ten years
  • Mortality of 2-3 yearly over ten years
  • 2.5 incidence of perioperative MI

54
CABG vs. Medical Rx
  • Three major randomized trials
  • A. VACS
  • B. ECSS
  • C. CASS
  • Improved mortality in CABG group
  • A. L-main CAD
  • B. 3-vessel CAD, esp. with decreased EF
  • C. LAD disease, severe angina, decreased EF

55
Stable Angina CABG
  • Nevertheless, bypass grafting remains a
    palliative procedure, as is every known treatment
    for coronary disease, and it assure permanent
    freedom neither from symptoms nor from a fatal
    coronary event
  • Hull R. Tex Hrt Jnl 198916127-129

56
Stable Angina Treatment Options
  • PTCA

57
PTCA vs. Medical Management
  • Review of six major trials
  • Greater symptomatic benefit in PTCA group
  • No change in mortality or rates of MI
  • Higher rate of CABG in PTCA group
  • BMJ 2000(Jul)32173-77.

58
PTCA vs Medical Management Multivessel Disease
59
Stable Angina Results of PTCA
  • 80 or greater success rate
  • 1 mortality
  • 3-5 emergency CABG ( prior to stenting )
  • 4 acute MI

60
CABG vs PTCA Multivessel Disease
  • Review of six major randomized trials
  • Most patients had preserved LVEF
  • No differences in mortality or combined endpoint
    of death and nonfatal MI
  • Second revascularization procedure more likely in
    first year after PTCA
  • Surgery patients more likely to be angina free at
    one year

61
CABG vs. PTCA Multivessel Disease
  • Most patients had 2-vessel CAD, preserved LVEF,
    and suitable anatomy

62
CABG vs. PTCA
  • BARI Trial Subset of Diabetic Patients
  • A. Five-year survival better in CABG group
  • B. Increased incidence of MI at eight years
  • C. More women, hypertension, CHF, and severe
    concomitant noncardiac disease
  • D. More multi-vessel disease, significant
    lesions, and distal lesions

63
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

64
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

65
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

66
Chronic Angia Reading List
  • Gersh BJ, Solomon AJ. Management of chronic
    stable angina medical therapy, PTCA, and CABG.
    Ann Internal Med 1998(FEB)128216-223.

67
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