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Management of Stable Angina Pectoris

Management of Stable Angina Pectoris. David Putnam, MD Albany Medical College. 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

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Management of Stable Angina Pectoris

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  1. Management ofStable Angina Pectoris David Putnam, MD Albany Medical College

  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. Stable AnginaClassification • Exertional • Variant • Anginal Equivalent Syndrome • Prinzmetal’s Angina • Syndrome-X • Silent Ischemia

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

  5. 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

  6. Angina: Anginal Equivalent Syndrome • Patient’s with exertional dyspnea rather than exertional chest pain • Caused by exercise induced left ventricular dysfunction

  7. Angina: Prinzmetal’s Angina • Spasm of a large coronary artery • Transmural ischemia • ST-Segment elevation at rest or with exercise • Not very common

  8. 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

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

  10. Angina: Treatment Goals • Feel better • Live longer

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

  12. Stable Angina Risk stratification • Noninvasive testing • Cardiac catheterization

  13. Stable AnginaEvaluation of LV Function • Physical exam • CXR • Echocardiogram

  14. Stable AnginaEvaluation of Ischemia • History • Baseline Electrocardiogram • Exercise Testing

  15. 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 CCSC Angina Classification

  16. Stable AnginaExercise Testing • The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation

  17. Angina: Exercise TestingHigh Risk Patients • 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

  18. Angina: Exercise TestingLow Risk Group 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

  19. 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

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

  21. Stable AnginaGuidelines for Nuclear EST Defined CAD • Post infarct risk stratification • Risk stratification to determine need for revascularization ( viability study )

  22. Stable AnginaDipyridamole 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 )

  23. 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 1996;77:139-42

  24. Stable AnginaStress Echo • Ischemia may cause wall motion abnormalities, no rise of fall in LVEF • Sensitivity/specificity same as nuclear testing • May be better in women

  25. Exercise TestingContraindications • MI—impending or acute • Unstable angina • Acute myocarditis/pericarditis • Acute systemic illness • Severe aortic stenosis • Congestive heart failure • Severe hypertension • Uncontrolled cardiac arrhythmias

  26. Stable AnginaNon-Invasive Evaluation

  27. Cardiac CatheterizationIndications • 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

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

  29. Stable AnginaTreatment Options

  30. Stable AnginaTreatment Options • Medical Treatment

  31. Stable AnginaCurrent Pharmacotherapy • Beta-blockers • Calcium channel blockers • Nitrates • Aspirin • Statins • ? ACE inhibitors

  32. Stable AnginaConsiderations when Choosing a Drug • Effect on myocardium • Effect on cardiac conduction system • Effect on coronary/systemic arteries • Effect on venous capitance system • Circadian rhytm

  33. 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

  34. Beta-Blockers

  35. Beta BlockersSide Effects • Bronchospasm • Diminished exercise capacity • Negative inotropy • Sexual dysfunction • Bradyarrhythmia • Masking of hypoglycemia • Increased claudication • Hair loss

  36. Beta BlockersCommon Available Agents • Propranolol • Atenolol • Metoprolol • Nadolol • Timolol

  37. Calcium Channel BlockersMechanisms 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

  38. Calcium Channel BlockersMechanisms of Action

  39. Calcium Channel BlockersMechanisms of Action

  40. Calcium Channel BlockersSide Effects • Palpitations • Headache • Ankle edema • Gingival hyperplasia

  41. Calcium Channel BlockersAvailable Agents • Verapamil • Diltiazem • Nifedipine • Nicardipine • Amlodipine • Felodipine • Nisoldipine • Bepridil

  42. NitratesMechanisms of Action • Nitric oxide has been identified as endothelium-derived relaxing factor • Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

  43. NitratesMechanisms 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

  44. NitratesReducing 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

  45. NitratesSide Effects • Headache • Flushing • Palpitations • Tolerance

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

  47. NitratesCommon Available Agents • Isorbide dinitrate • Isorbide mononitrate • Long-acting transdermal patches • Nitroglycerin sl

  48. Stable AnginaTreatment Options • CABG

  49. Stable AnginaTreatment Options • PTCA

  50. Stable Angina: 1-Vessel CADTherapeutic 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

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