Transcript Management of Stable Angina Pectoris, type, stable angina

This lecture was conducted during the Nephrology Unit
Grand Ground by Medical Student rotated under Nephrology
Division under the supervision and administration of Prof.
Jamal Al Wakeel, Head of Nephrology Unit, Department of
Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the
Department of Medicine. Nephrology Division is not
responsible for the content of the presentation for it is
intended for learning and /or education purpose only.
Angina Pectoris
Presented by:
Nasrullah Nasrullah
Medical Student
February 2009
N.A.N 2009
Objective
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Definition of angina.
Types of angina.
Classification of angina.
Causes.
Most risk factors.
Investigation.
Treatment in general.
Summury.
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Definition of Angina Pectoris
• is the result of myocardial ischemia caused by an
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imbalance between myocardial blood supply and
oxygen demand.
Angina is a common presenting symptom
(typically, chest pain) among patients with
coronary artery disease.
Angina pectoris is more often the presenting
symptom of coronary artery disease in women than
in men.
Increase with age
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Types of angina
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2.
Stable angina.
Unstable angina
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Stable angina
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is that occurs when coronary perfusion is
impaired by fixed or stable atheroma of
coronary arteries.
Ex. Pt. has fixed capacity of exertion after
he starts feeling chest pain.
Unstable angina
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is that characterized by rapidly worsening
chest pain on minimal exertion or at rest.
= ulcerated atheroma+ thrombus
formation>>> reduction of coronary blood
flow caused by thrombus>> angina at rest
Unstable angina
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Recent onset (less than 1 month).
Increase frequency and duration of episode.
Angina at rest not responding readily to
therapy.
If the pain more than 30 min.????
MI
Stable Angina Classification
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Exertional
Variant or Prinzmetal’s Angina
Anginal Equivalent Syndrome
Syndrome-X
Silent Ischemia
Decubitus angina
Noctural angina
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Exertional or classical
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It occurs due to increase myocardial oxygen
demand during exertion or emotion in a
patient of narrow coronary arteries. It
relieved by rest and nitroglycerine.
Coronary artery obstructions are not
sufficient to result in resting myocardial
ischemia. However, when myocardial
demand increases, ischemia results.
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Variant or Prinzmetal’s Angina
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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
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Prinzmetal’s Angina
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Spasm of a large coronary artery
Transmural ischemia
ST-Segment elevation at rest or with
exercise
More prolonged than in classical angina.
It occurs more in women under age 50.
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Anginal Equivalent Syndrome
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Patient’s with exertional dyspnea rather than
exertional chest pain
Caused by exercise induced left ventricular
dysfunction
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Syndrome X
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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
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Silent Ischemia
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Very common
More episodes of silent than painful
ischemia in the same patient
Difficult to diagnose
Holter monitor
Exercise testing
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Holter monitor
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Decubitus angina
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Occurs when pt. lies down.
Usually ass. With impaired LV function.
Pt usually has severe CAD when pt, has
these symptoms,
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Noctural angina
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It awakes the pt. from sleep,
It may provoked by vivid dreams.
It may occur due to CAO or coronary spasm
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The Canadian Cardiovascular Society
grading scale
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Class I : Angina only during strenuous or prolonged physical
activity
Class II : Slight limitation, with angina only during vigorous
physical activity
Class III : Symptoms with everyday living activities, ie, moderate
limitation
Class IV : Inability to perform any activity without angina or
angina at rest, ie, severe limitation
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The New York Heart Association
classification
• is also used to quantify the functional limitation imposed by
patients' symptoms, as follows:
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Class I : No limitation of physical activity (Ordinary physical activity
does not cause symptoms.)
Class II : Slight limitation of physical activity (Ordinary physical activity
does cause symptoms.)
Class III : Moderate limitation of activity (Patient is comfortable at rest,
but less than ordinary activities cause symptoms.)
Class IV : Unable to perform any physical activity without discomfort,
therefore severe limitation (Patient may be symptomatic even at rest.)
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Causes:
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Decrease in myocardial blood supply due to increased
coronary resistance in large and small coronary
arteries:
Significant coronary atherosclerotic lesion in the large epicardial
coronary arteries (ie, conductive vessels) with at least a 50%
reduction in arterial diameter
Coronary spasm (ie, Prinzmetal angina)
Abnormal constriction or deficient endothelial-dependent relaxation
of resistant vessels associated with diffuse vascular disease (ie,
microvascular angina)
Syndrome X
Systemic inflammatory or collagen vascular disease, such as
scleroderma, systemic lupus erythematous, Kawasaki disease,
polyarteritis nodosa, and Takayasu arteritis
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Cause cont.
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Increased extravascular forces, such as severe LV
hypertrophy caused by hypertension, aortic stenosis, or
hypertrophic cardiomyopathy, or increased LV diastolic
pressures
Reduction in the oxygen-carrying capacity of blood, such as
elevated carboxyhemoglobin or severe anemia (hemoglobin,
<8 g/dL)
Congenital anomalies of the origin and/or course of the major
epicardial coronary arteries
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Causes cont.
• Structural abnormalities of the coronary
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arteries
Congenital coronary artery aneurysm or
fistula
Coronary artery ectasia
Coronary artery fibrosis after chest radiation
Coronary intimal fibrosis following cardiac
transplantation
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Risk factors:
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Major risk factors for atherosclerosis: like family
history of premature CAD, cigarette
smoking,DM,hypercholesterolemia(Metabolic
syndrome), or systemic HTN
Other risk factors: These include LV hypertrophy,
obesity,
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Precipitating factors:
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These include factors such as severe
anemia, fever, tachyarrhythmias,
catecholamines, emotional stress, and
hyperthyroidism, which increase
myocardial oxygen demand.
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Preventive factors:
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Factors associated with reduced risk of
atherosclerosis are a high serum HDL
cholesterol level, physical activity,
estrogen, and moderate alcohol intake (12 drinks/d).
???!! Plz Don’t drink and smoke 4u life.
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Stable Angina
Evaluation of LV Function
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Physical exam
CXR
Echocardiogram
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Stable Angina
Evaluation of Ischemia
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History
Baseline Electrocardiogram
Exercise Testing
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CCSC Angina Classification
• Class I
• Angina only with
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• Class III
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• Class IV
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extreme exertion
Angina with walking
1 to 2 blocks
Angina with walking
1 block
Angina with minimal
activity
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ECG
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ST segment depression with or without T
wave inversion that reverse after ischemia
disappears.
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ECG
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Elevation of ST segment in prinzmental’s
angina.
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ECG
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The resting ECG may be normal between
attacks however it may show old MI, heart
block or LVH
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Stable Angina
Exercise Testing
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The goal of exercise testing is to induce a
controlled, temporary ischemic state during
clinical and ECG observation
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Angina: Exercise Testing
High Risk Patients
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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
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Angina: Exercise Testing
Low Risk Group
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CASS Registry: 7 year survival
Less than 1 mm ST depression in Stage III
of Bruce Protocol
Annual mortality: 1.3%
JACC 1986;8:741-8
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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
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Stable Angina
Stress Echo
• Ischemia may cause wall motion abnormalities, no
rise of fall in LVEF ( left ventricular ejection fraction )
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This formula gives one a fraction, e.g., 0.60. Multiply this fraction by 100 gives a % figure, e.g., 60%
• Sensitivity/specificity same as nuclear testing
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Cardiac Catheterization
Indications
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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
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percutaneous transluminal coronary angioplasty
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coronary artery bypass grafting
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Angina: Treatment Goals
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Feel better
Live longer
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Stable Angina
Treatment Options
Angina
Treatment Options
Medicine
Percutaneous
Intervation
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CABG
Stable Angina
Non-Invasive Evaluation
Nondisabling Angina
Resting LV Function
(Clinical Assessment)
LV Dysfunction
Normal LV Function
Coronary Arteriography
Stress Testing
High Risk
Low Risk
Coronary Arteriography
Medical Therapy
Stable
Recurrent Angina
Medical Therapy
Coronary Arteriography
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Stable Angina
Treatment Options
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Medical Treatment
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Stable Angina
Current Pharmacotherapy
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Beta-blockers
Calcium channel blockers
Nitrates
Aspirin
Statins
? ACE inhibitors
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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
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Reference
• Medical diagnosed and mangement 8th 2006 ,mohammed
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Danish
OHCM 7th
250 cases in clinical examination.
pocket clincal medicine 3nd. Kumar & Clark
http://www.ncbi.nlm.nih.gov/
http://emedicine.medscape.com/article/150215-overview
http://www.heartfailurematters.org
http://health.allrefer.com/
Ect…..
N.A.N 2009
THANKS 4 HEARING MY
PRESENTATION
I hope that it is useful
My best regards
NASRULLAH NASRULLAH (N.A.N)