Chronic stable angina

Dr TabanInternist & cardiologist

MAGNITUDE OF THE PROBLEM Lifetime risk of CAD after 40Y: • Men = 49%• Women =32%

52% cardiac deathOne of six all death

Stable Angina .

Not new onsetNot new onset

Not at rest chest painNot at rest chest pain

The commonest cause isThe commonest cause is ADVANCED ADVANCED ATHEROSCELEROSISATHEROSCELEROSIS

Not new exacerbatedNot new exacerbated

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Chest pain caused by transient

myocardial ischemia due to an

imbalance between myocardial

oxygen supply and demand.4

Transient Myocardial Transient Myocardial ischemiaischemia

Severe Chest painSevere Chest pain

Myocardial Blood Flow

Myocardial O2 Demands

Fixed threshold angina

Variable threshold angina

Clinical Manifestations

Differential Diagnosis of Chest Pain

• FIXED-THRESHOLD= Angina Caused by Increased Myocardial O2 Requirements

• VARIABLE-THRESHOLD = Angina Caused by Transiently Decreased O2 Supply

• MIXED ANGINA.

Differential Diagnosis of Chest Pain

Physical Examination

Pathophysiology

Noninvasive Testing • Biochemical Tests :Aop-ProB, LPa, LDL(smal dense), LP-PL A, homocysteinInflammation: hsCRP, BNP, Soluble CD4, Risk factors: FBS, HBA1c &…

• Resting Electrocardiogram

• Noninvasive Stress Testing

Resting Electrocardiogram

50% durig pain = NL-ECG

50% between attacks 50% between attacks :: ECG is entirelyECG is entirely NORMALNORMAL

Other : old problemsOther : old problems

Exercise ECG showing typical severe down sloping Exercise ECG showing typical severe down sloping ST ST segmentsegment : :

Anginal pain is often associated with Depression Anginal pain is often associated with Depression of of STST segment segment

Standing 1 min. 3 min. 7 min. 9 min.

Noninvasive Stress Testing

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• Computed Tomography (MSCT):90%=sensitivity 50% = specificity

• Cardiac Magnetic Resonance Imaging

Catheterization, Angiography, and Coronary Arteriography

• SVD = 2VD = 3VD = 25%.• LML = 5 – 10%.• NL-CAG = 15%.

diffuse disease than MI

Natural History of Angina Pectoris and Risk Stratification

Management of Stable Angina(1) identification and treatment of associated diseases that can

precipitate or worsen angina;

(2) reduction of coronary risk factors;

(3) application of general and nonpharmacological methods, with particular attention to adjustments in life style;

(4) pharmacological management;

(5) revascularization by percutaneous catheter-based techniques or by coronary bypass surgery

Stop smokingStop smoking Reduce weightReduce weight

Treat Hypertension , Treat Hypertension , Hypercholestrolimia Hypercholestrolimia

and Diabetes and Diabetes

AVOID AVOID Severe Severe exertionexertion

Heavy mealHeavy meal EmotionsEmotions Cold WeatherCold Weather

General measures

20•Graduated exercise may open new collaterals

Treatment of an acute attack of anginaSublingualSublingual nitroglycerin nitroglycerin (0.5 mg ) or isosorbide (0.5 mg ) or isosorbide

dinitrate (5 mg ) dinitrate (5 mg ) or Oral sprayOral spray nitroglycerinnitroglycerin (0.4 mg/metered (0.4 mg/metered

dose), dose), isosorbide dinitrateisosorbide dinitrate(1.25 mg/metered (1.25 mg/metered dose) dose)

Relief within 1-3 min. Persistence of pain

Repeat nitroglycerin at 5 min. Repeat nitroglycerin at 5 min. interval (3 tab. max.)interval (3 tab. max.)

Relief not relieved

InfarctionHOSPITALIZATION

What are the antianginal drugs?

Organic nitrates.

Calcium channel blockers.

- adrenoceptor blockers.

-blocker + Long

acting Nitrate

-blocker +

Nifedipine/amilodipin

Verapamil or Diltiazem +

Nitrate

-blocker + Nitrate +

Nifedipine/amilodipin

????

??

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Anti-platelet

• ASPIRIN

• CLOPIDOGREL

Rx for Risk factors

• HTN

• DM

• HLP - statins

• ACE-Inh:

Management of Variant Angina

Nitrates andNitrates and/or /or Ca-Ca- Channel Channel blockersblockersFor the acute attack & prophylaxisFor the acute attack & prophylaxis

Beta-Blocker?Beta-Blocker?

ASA?ASA?

For patients not responding to adequate medical For patients not responding to adequate medical therapy:therapy:

•Percutaneous Transluminal coronary Percutaneous Transluminal coronary Angioplasty (PTCA)Angioplasty (PTCA)

•Coronary artery bypass grafting (CABG)Coronary artery bypass grafting (CABG)

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