Treatment Strategy Of Chronic Stable Angina

1. Treatment Strategy Of Chronic Stable Angina

2. Angina: Treatment Goals Feel better Live longer

3. The Goals of Therapy in CAD To improve quality of life (symptoms) To reduce mortality To reduce morbidity To reduce progression of disease and induce regression.

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

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

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

7. Stable AnginaEvaluation of Ischemia History Baseline Electrocardiogram Exercise Testing

8. CCSC Angina Classification • 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

9. Stable AnginaNon-Invasive Evaluation

10. Cardiac CatheterizationIndications

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

13. Treatment of Chronic Stable Angina Medical Revascularization PCI ACBG

14. Stable AnginaTreatment Options Medical Treatment

16. MEDICAL THERAPY ANTIPLATELETS BETA BLOCKERS NITRATES CALCIUM ANTAGONIST ACEI STATINS NEW THERAPIES

17. 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

19. Pharmacotherapy for Chronic Stable Angina (class I) 1. Aspirin in the absence of contraindications A  2. Beta-blockers as initial therapy in the absence of contraindications in patients with prior myocardial infarction or without prior myocardial infarction A,B  3. ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic dysfunction A  4. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol >130 mg/dl, with a target LDL of <70 mg/dl A  5. Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina B  6. Calcium antagonists†or long-acting nitrates as initial therapy for reduction of symptoms when beta blockers are contraindicated B  7. Calcium antagonists † or long-acting nitrates in combination with beta blockers when initial treatment with beta blockers is not successful B  8. Calcium antagonists † and long-acting nitrates as a substitute for beta blockers if initial treatment with beta blockers leads to unacceptable side effects

20. Pharmacotherapy for Chronic Stable Angina (class IIa) • 1. Clopidogrel when aspirin is absolutely contraindicated • 2. Long-acting non-dihydropyridine calcium antagonists † instead of beta blockers as initial therapy B • 3. In patients with documented or suspected CAD and LDL cholesterol 100–129 mg/dl, several therapeutic options are available: B  •    a. Lifestyle and/or drug therapies to lower LDL to <70 mg/dl   •    b. Weight reduction and increased physical activity in persons with the metabolic syndrome   •    c. Institution of treatment of other lipid or non-lipid risk factors; consider use of nicotinic acid or fibric acid for elevated triglycerides or low HDL cholesterol  •  4. ACE inhibitor in patients with CAD or other vascular disease

21. 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

24. Cardiac effects of β-adrenergic blocking drugs at the levels of the SA node, AV node, conduction system, and myocardium

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

26. Beta BlockersCommon Available Agents Propranolol Atenolol Metoprolol Carvediloll

27. BB for clinical use

28. 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

29. Calcium Channel BlockersMechanisms of Action

30. Calcium Channel BlockersMechanisms of Action

31. Mechanisms of anti-ischemic effects of calcium channel blockers

32. Calcium Channel BlockersSide Effects Palpitations Headache Ankle edema Gingival hyperplasia

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

34. Contraindications to verapamil or diltiazem

35. Contraindications to dihydropyridines

36. Properties of CCB in clinical use

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

38. 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

40. Schematic diagram of effects of nitrate on the circulation

42. Nitrates in Angina

43. 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

44. NitratesSide Effects Headache Flushing Palpitations Tolerance

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

46. Dual role of ACE inhibitors, both preventing and treating cardiovascular disease

48. ACC/AHA Guidelines for Treatment of Risk Factors (class I) 1. Treatment of hypertension according to Joint National Conference VI guidelines A  2. Smoking cessation therapy B  3. Management of diabetes C  4. Comprehensive cardiac rehabilitation program (including exercise) B  5. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol ≥100 mg/dl, with a target LDL of <70mg/dl A  6. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus C

49. Specific Goals for Risk Reduction Strategies in Patients with Chronic Stable Angina Smoking Complete cessation Blood pressure <140/90 or 130/85 mm Hg if heart failure or renal insufficiency; <130/85 mm Hg if diabetes Lipid management Primary goal: LDL <70mg/dl Secondary goal: If triglycerides ≥200 mg/dl, then non-HDL should be <130 mg/dl Physical activity Minimum goal: 30 min 3 or 4 d/w Optimal goal: daily Weight management BMI 18.5–24.9 kg/m2 Diabetes management HbA1c <7%

50. Stable AnginaTreatment Options CABG