Transcript The Goals of Therapy in CAD

Seyed Mohammad Hashemi
Professor of Cardiology
CHRONIC STABLE ANGINA
Non Pharmachologic Therapy
ANGINA
A
careful history and physical
examination is critical to
accurately establish the
diagnosis of angina pectoris and
to exclude other causes of chest
pain.
PATHOPHYSIOLOGY OF ISCHEMIC CHEST PAIN
Angina
is caused by myocardial
ischemia which occurs
whenever myocardial oxygen
demand exceeds oxygen supply
Provoking Factors Of The Chest Pain
 Angina
is often elicited by activities and
situations which increase myocardial
oxygen demand, including physical
activity, cold, emotional stress, sexual
intercourse, meals, or lying down .
 It has been strongly recommended that
patients also be questioned about
cocaine use .
QUALITY OF THE CHEST PAIN
Angina is often characterized more as a
discomfort than pain, and may be difficult to
describe
 squeezing, tightness, pressure, constriction,
strangling, burning, heart burn, fullness in the
chest,, lump in throat, ache, heavy weight on
chest (elephant sitting on chest)
 Levine sign

Radiation Of The Chest Pain
 Angina
often radiates to other parts of
the body including the upper
abdomen (epigastric), shoulders,
arms (upper and forearm), wrist,
fingers, neck and throat, lower jaw
and teeth (but not upper jaw), and
rarely to the back (specifically the
interscapular region).
Site Of The Chest Pain



Visceral Pain
Visceral fibers enter the spinal cord at several levels
leading to poorly localized, poorly characterized pain.
(discomfort, heaviness, dull, aching)
Heart, blood vessels, esophagus and visceral pleura
are innervated by visceral fibers
Because of dorsal fibers can overlap three levels
above or below, disease of thoracic origin can produce
pain anywhere from the jaw to the epigastrum
Site Of The Chest Pain
Parietal Pain
 Parietal
pain, in contrast to visceral pain,
is described as sharp and can be
localized to the dermatome superficial to
the site of the painful stimulus.
 The dermis and parietal pleura are
innervated by parietal fibers.
Timing Of The Chest Pain

Angina occurs more commonly in the morning
due to a morning diurnal increase in
sympathetic tone. Enhanced sympathetic
activity raises heart rate, blood pressure, vessel
tone and resistance (resulting in a reduced
vessel diameter which causes any fixed lesion
to be more occlusive), and platelet
aggregability.
Time Of The Chest Pain
More
than 5 min and
less than 20 min.
ASSOCIATED SYMPTOMS OF THE CHEST
PAIN
most common : shortness of
breath, may reflect mild pulmonary
congestion resulting from ischemiamediated diastolic dysfunction.
 Other symptoms may include belching,
nausea, indigestion, diaphoresis,
dizziness, lightheadedness, clamminess,
and fatigue.
 The
7/18/2015
THE GOALS OF THE THERAPY OF STABLE
ANGINA INCLUDE:
Relief of symptoms (To improve quality of life)
 Prevention or slowing of disease progression
 Prevention of future cardiac events, such as
MI, unstable angina, or the need for
revascularization
 Improvement in survival

16
THESE GOALS CAN BE ACHIEVED WITH A
VARIETY OF MODALITIES INCLUDING;
 Nonpharmacologic
and lifestyle
measures
 Medical therapy,
 Percutaneous coronary intervention
(PCI),
 surgical revascularization (CABG).
ACC/AHA GUIDELINES FOR TREATMENT OF RISK
FACTORS (CLASS I) AND SPECIFIC GOALS
 1.
Treatment of hypertension according to
Joint National Conference VI guidelines
 Blood
pressure <140/90 or 130/85 mm Hg
if heart failure or renal insufficiency;
<130/85 mm Hg if diabetes

2. Smoking cessation therapy
 Smoking
Complete cessation
ACC/AHA GUIDELINES FOR TREATMENT OF RISK
FACTORS (CLASS I) AND SPECIFIC GOALS


3. Management of diabetes
Diabetes management HbA1c <7%
4. Comprehensive cardiac
rehabilitation program (including
exercise)
Physical
activity Minimum goal: 30 min
3 or 4 d/w Optimal goal: daily
ACC/AHA GUIDELINES FOR TREATMENT OF RISK
FACTORS (CLASS I) AND SPECIFIC GOALS

5. LDL-lowering therapy in patients with
documented or suspected CAD and LDL cholesterol
≥130 mg/dl, with a target LDL of <100 mg/dl


Lipid management Primary goal: LDL <100
mg/dl Secondary goal: If triglycerides ≥200 mg/dl, then
non-HDL should be <130 mg/dl
Therapy to lower non-HDL cholesterol in patients with
documented or suspected CAD and triglycerides >200
mg/dl, with a target non-HDL cholesterol <130 mg/dl
ACC/AHA GUIDELINES FOR TREATMENT OF RISK
FACTORS (CLASS I) AND SPECIFIC GOALS

6. Weight reduction in obese patients in
the presence of hypertension,
hyperlipidemia, or diabetes mellitus
 Weight
management BMI 18.5–24.9 kg/m2
ACC/AHA GUIDELINES FOR TREATMENT OF RISK
FACTORS (CLASS IIB)
1. Folate therapy in patients with elevated
homocysteine levels
 2. Identification and appropriate treatment
of clinical depression to improve CAD
outcomes
 3. Intervention directed at psychosocial
stress reduction

ACC/AHA GUIDELINES FOR TREATMENT
OF RISK FACTORS (CLASS III)
1. Initiation of hormone replacement therapy in
postmenopausal women for the purpose of
reducing cardiovascular risk A
 2. Vitamins C and E supplementation A
 3. Chelation therapy C
 4. Garlic C
 5. Acupuncture C
 6. Coenzyme Q C

WALK-THROUGH ANGINA PHENOMENON
DURING EXERCISE

occurrence of mild angina during the first
stages of exercise with disappearance of
chest pain at higher workloads despite a
greater exercise.
CURRENT NONPHARMACOLOGIC
ANTIANGINAL STRATEGIES

Exercise Training

Enhanced external
counterpulsation (EECP)





 Endothelial function
Promotes coronary collateral
formation
 Peripheral vascular
resistance
 Ventricular function
Placebo effect
CURRENT NONPHARMACOLOGIC
ANTIANGINAL STRATEGIES

Transmyocardial revascularization (TMR)



Sympathetic denervation
Angiogenesis
Spinal cord stimulation (SCS)



 Neurotransmission
of painful stimuli
 Release of
endogenous opiates
Redistributes myocardial
blood flow to ischemic areas
TMR
Surgical
 surgeons use the laser to make between 20
and 40 tiny (one-millimeter-wide)

RATIONALE
improved perfusion by stimulation of
angiogenesis
 potential placebo effect
 anesthetic effect mediated by the destruction
of sympathetic nerves carrying pain-sensitive
afferent fibers
 Peri-procedural infarction.

PERCUTANEOUS TMR

Percutaneous
EECP
EECP

Increases arterial blood pressure and
retrograde aortic blood flow during diastole
(diastolic augmentation).

Cuffs are wrapped around the patients legs
and sequential pressure (300mmHg) is applied
in early diastole.
PATIENT SELECTION

Angina class III/IV
 Refractory
to medical therapy
 Reversible ischemia of the free wall
 not amenable for revascularization

Excluded if LVEF<20% or had current major
illness