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Chronic stable angina

Chronic stable angina. Dr Taban Internist & cardiologist. MAGNITUDE OF THE PROBLEM . Lifetime risk of CAD after 40Y: Men = 49% Women =32% 52% cardiac death One of six all death. Stable Angina . The commonest cause is ADVANCED ATHEROSCELEROSIS. Not new onset. Not at rest chest pain.

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Chronic stable angina

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  1. Chronic stable angina Dr Taban Internist & cardiologist

  2. MAGNITUDE OF THE PROBLEM Lifetime risk of CAD after 40Y: • Men = 49% • Women =32% 52% cardiac death One of six all death

  3. Stable Angina . The commonest cause isADVANCED ATHEROSCELEROSIS Not new onset Not at rest chest pain Not new exacerbated 3

  4. Chest pain caused bytransient myocardial ischemiadue to animbalance betweenmyocardial oxygen supply and demand. 4

  5. Myocardial Blood Flow Myocardial O2 Demands Clinical Manifestations Differential Diagnosis of Chest Pain Transient Myocardial ischemia Fixed threshold angina Variable threshold angina Severe Chest pain

  6. FIXED-THRESHOLD= Angina Caused by Increased Myocardial O2 Requirements • VARIABLE-THRESHOLD = Angina Caused by Transiently Decreased O2 Supply • MIXED ANGINA.

  7. Differential Diagnosis of Chest Pain

  8. Physical Examination

  9. Pathophysiology

  10. Noninvasive Testing • Biochemical Tests : Aop-ProB, LPa, LDL(smal dense), LP-PL A, homocystein Inflammation: hsCRP, BNP, Soluble CD4, Risk factors: FBS, HBA1c &… • Resting Electrocardiogram • Noninvasive Stress Testing

  11. Resting Electrocardiogram 50% between attacks :ECG is entirelyNORMAL Other : old problems 50% durig pain = NL-ECG

  12. Noninvasive Stress Testing Anginal pain is often associated with Depression of ST segment Exercise ECG showing typical severe down sloping ST segment : Standing 7 min. 9 min. 1 min. 3 min. 13

  13. Computed Tomography (MSCT): 90%=sensitivity 50% = specificity • Cardiac Magnetic Resonance Imaging

  14. Catheterization, Angiography, and Coronary Arteriography • SVD = 2VD = 3VD = 25%. • LML = 5 – 10%. • NL-CAG = 15%. diffuse disease than MI

  15. Natural History of Angina Pectoris and Risk Stratification

  16. 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

  17. General measures Treat Hypertension , Hypercholestrolimia and Diabetes Stop smoking Reduce weight AVOID Severe exertion Heavy meal Emotions Cold Weather • Graduated exercise may open new collaterals 20

  18. Persistence of pain Relief within 1-3 min. Treatment of an acute attack of angina Sublingual nitroglycerin (0.5 mg ) or isosorbide dinitrate (5 mg ) or Oral spraynitroglycerin (0.4 mg/metered dose), isosorbide dinitrate(1.25 mg/metered dose) Repeat nitroglycerin at 5 min. interval (3 tab. max.) Relief not relieved Infarction HOSPITALIZATION

  19. What are the antianginal drugs? Organic nitrates. - adrenoceptor blockers. Calcium channel blockers.

  20. Combination Therapy in Angina Pectoris ? Verapamil or Diltiazem + Nitrate b-blocker + Long acting Nitrate ? ? ? b-blocker + Nitrate + Nifedipine/amilodipin b-blocker + Nifedipine/amilodipin

  21. Anti-platelet • ASPIRIN • CLOPIDOGREL

  22. Rx for Risk factors • HTN • DM • HLP - statins

  23. ACE-Inh:

  24. Management of Variant Angina Nitrates and/or Ca-Channel blockers For the acute attack & prophylaxis Beta-Blocker? ASA?

  25. Coronary Artery Revascularization • For patients not responding to adequate medical therapy: • Percutaneous Transluminal coronary Angioplasty (PTCA) • Coronary artery bypass grafting (CABG) 28

  26. Tank you for your attention You can download this slid in : Any question? www. g a l b . ir

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