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CHRONIC STABLE CHRONIC STABLE ANGINAANGINA
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A 47-year-old man reports a six-month history of intermittent chest discomfort while playing squash. He describes lower substernal tightness with numbness of the left upper arm only during exertion. He does not smoke. His father died suddenly at the age of 49 years. His blood pressure is 138/84 mm Hg. The level of total cholesterol is 261 mg per deciliter (6.7 mmol per liter), of low-density lipoprotein cholesterol 172 mg per deciliter (4.4 mmol per liter), and of high-density lipoprotein cholesterol 50 mg per deciliter (1.3 mmol per liter), and the triglyceride level is 113 mg per deciliter (2.9 mmol per liter). The result of an exercise test is positive, with pain and 1.5 mm of horizontal ST-segment depression at stage 4 of the Bruce protocol. How should the patient's case be managed?
2Abrams,NEJM,2005;352:2524-2533
Case history
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Chronic Stable AnginaChronic Stable Angina
1.1. PathophysiologyPathophysiology
2.2. DiagnosisDiagnosis
3.3. ManagementManagement1.1. Lifestyle modificationLifestyle modification
2.2. Antianginal therapyAntianginal therapy1.1. MedicationMedication
2.2. InvasiveInvasive
3.3. OtherOther
3.3. Vasculoprotective therapyVasculoprotective therapy3
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Typical Progression of Coronary Atherosclerosis.
4Abrams,NEJM,2005;352:2524-2533
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Symptoms of Angina.
Abrams J. N Engl J Med 2005;352:2524-2533.
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Classification and Severity of Angina.
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Abrams,NEJM,2005;352:2524-2533
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Common Stress-Testing Procedures for the Evaluation of Chest Pain.
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1.Lifestyle Modification
1. Regular aerobic activity
2. Diet
3. Tobacco abstinence and
avoidance of passive smoke
4. Logistics
2.Optimize non cardiac comorbidities
Non Pharmacologic Therapy
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Recommended Antianginal Drugs.
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The Vasculoprotective Regimen for Stable Angina.
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Boden WE, ORourke, RA, Teo KK, Hartigan P, Maron D, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356:1503-16.
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Study OverviewStudy Overview In a randomized trial, 2287 patients with In a randomized trial, 2287 patients with
coronary artery disease and evidence of coronary artery disease and evidence of ischemia were assigned to receive optimal ischemia were assigned to receive optimal medical therapy with or without percutaneous medical therapy with or without percutaneous coronary intervention (PCI)coronary intervention (PCI)
At a median of 4.6 years, the rates of death and At a median of 4.6 years, the rates of death and myocardial infarction were 19.0% in the PCI myocardial infarction were 19.0% in the PCI group and 18.5% in the medical-therapy groupgroup and 18.5% in the medical-therapy group
The PCI group had lower rates of angina and The PCI group had lower rates of angina and repeat revascularizationrepeat revascularization
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Kaplan-Meier Survival Curves
Boden WE et al. N Engl J Med 2007;356:1503-1516
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Courage TrialCourage Trial
As an initial management strategy As an initial management strategy in patients with stable coronary in patients with stable coronary artery disease, PCI did not reduce artery disease, PCI did not reduce the risk of death, myocardial the risk of death, myocardial infarction, or other major infarction, or other major cardiovascular events when added cardiovascular events when added to optimal medical therapyto optimal medical therapy
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ConclusionsConclusions Diagnosis of chronic stable angina is Diagnosis of chronic stable angina is
made on the basis of stable anginal made on the basis of stable anginal symptoms, non-invasive stress symptoms, non-invasive stress testing indicating ischemia, and as testing indicating ischemia, and as appropriate coronary angiography.appropriate coronary angiography.
Antianginal drugs should be Antianginal drugs should be prescribed to relieve symptoms. prescribed to relieve symptoms. Beta blockers should be used unless Beta blockers should be used unless contraindicated or not tolerated.contraindicated or not tolerated.
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Lifestyle modification and Lifestyle modification and management of non-cardiac management of non-cardiac comorbidities is important.comorbidities is important.
It needs to be understood that It needs to be understood that coronary artery disease is a chronic coronary artery disease is a chronic condition, which is manageable but condition, which is manageable but not curable.not curable.
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Vasculoprotective therapy is important Vasculoprotective therapy is important including antiplatelet agents such as including antiplatelet agents such as aspirin and clopidogrel, statins, and ACEIaspirin and clopidogrel, statins, and ACEI
Under most circumstances, optimal Under most circumstances, optimal medical therapy is primary approach medical therapy is primary approach and revascularization should be and revascularization should be considered as needed or for special considered as needed or for special coronary anatomy.coronary anatomy.
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Chronic Stable AnginaReferences
1. Abrams J. Chronic Stable Angina. N Engl J Med 2005;352:2524-33.
2 . Fraker TD Jr, Fihn SD. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guideline for the Management of Patients with Chronic Stable Angina. J. Am. Coll. Cardiol. 2007;50:2264-2274.
3. Boden WE, ORourke, RA, Teo KK, Hartigan P, Maron D, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356:1503-16.
4. Hochman JS, Steg PG. Does Preventive PCI Work? N Engl J Med 2007;356:1572-1574. 5. Peterson ED, Rumsfeld JS. Finding the Courage to Reconsider Medical Therapy for Stable
Angina. N Engl J Med 2008;359:7:751-753. 6. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, et al. Coronary Intervention for
Persistent Occlusion after Myocardial Infarction. N Engl J Med 2006;355:2395-407. 7. Mark DB, Pan W, Clapp-Channing NE, Anstrom KJ, et al. Quality of Life after Late Invasive
Therapy for Occluded Arteries. N Engl J Med 2009;360:774-83.
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Quiz-Question 1Quiz-Question 1
What is best initial screening test What is best initial screening test for patient with stable exertional for patient with stable exertional angina, arthritis, hypertension, and angina, arthritis, hypertension, and LBBB?LBBB?
1.1. Treadmill stress echoTreadmill stress echo
2.2. Dobutamine stress echoDobutamine stress echo
3.3. Lexiscan stress myocardial scanLexiscan stress myocardial scan
4.4. Dobutamine stress myocardial scanDobutamine stress myocardial scan
5.5. Treadmill stress myocardial scan.Treadmill stress myocardial scan.
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Quiz-Question 2Quiz-Question 2
What is best test for a patient with What is best test for a patient with known stable angina who awakens known stable angina who awakens from sleep with anginal type chest from sleep with anginal type chest pain for the first time?pain for the first time?
1.1. Treadmill exercise test.Treadmill exercise test.
2.2. Lexiscan stress myocardial scanLexiscan stress myocardial scan
3.3. Dobutamine stress echoDobutamine stress echo
4.4. Cardiac catheterizationCardiac catheterization
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Quiz-Question 3Quiz-Question 3
When added to optimal medical When added to optimal medical therapy for chronic stable therapy for chronic stable angina, PCI prolongs life and angina, PCI prolongs life and reduces chance of myocardial reduces chance of myocardial infarctioninfarction TrueTrue FalseFalse
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Quiz-Question 4Quiz-Question 4
Which drug is Which drug is vasculoprotective?vasculoprotective?
1.1. Isosorbide dinitrateIsosorbide dinitrate
2.2. AmlodipineAmlodipine
3.3. AtorvastatinAtorvastatin
4.4. DiltiazemDiltiazem
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