Management
of
Stable Angina Pectoris
Bushra Abdul Hadi
Angina Pectoris
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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.
Angina
Stable Angina
Classification
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Exertional
Variant
Anginal Equivalent Syndrome
Prinzmetal’s Angina
Syndrome-X
Silent Ischemia
Angina: Exertional
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Coronary artery obstructions are not
sufficient to result in resting myocardial
ischemia. However, when myocardial
demand increases, ischemia results.
Angina: Variant 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
Angina: Anginal Equivalent Syndrome
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Patient’s with exertional dyspnea rather than
exertional chest pain
Caused by exercise induced left ventricular
dysfunction
Angina: Prinzmetal’s Angina
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Spasm of a large coronary artery
Transmural ischemia
ST-Segment elevation at rest or with
exercise
Not very common
Angina: 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
Angina: 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
Angina: Treatment Goals
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Feel better
Live longer
Angina: Prognosis
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Left ventricular function
Number of coronary arteries with significant
stenosis
Extent of jeoporized myocardium
Stable Angina
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Risk stratification
Noninvasive testing
Cardiac catheterization
Stable Angina
Evaluation of LV Function
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Physical exam
CXR
Echocardiogram
Stable Angina
Evaluation of Ischemia
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History
Baseline Electrocardiogram
Exercise Testing
CCSC Angina Classification
• Class I
• Angina only with
• Class II
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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
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
Angina: Exercise Testing
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
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
ECG Treadmill EST in Women
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Higher false-positive rate
Reduces procedures without loss of
diagnostic accuracy
Only 30% of women need be referred for
further testing
Stable Angina
Guidelines for Nuclear EST
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Diagnosis/prognosis for CAD
Non-diagnostic EST
Abnormal resting ECG
Negative EST with continued chest pain
Intermediate probability of disease
Stable Angina
Guidelines for Nuclear EST
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Defined CAD
Post infarct risk stratification
Risk stratification to determine need for
revascularization ( viability study )
Stable Angina
Dipyridamole Nuclear EST
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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 )
Appropriateness of
Radionuclide Exercise Testing
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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
Stable Angina
Stress Echo
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Ischemia may cause wall motion
abnormalities, no rise of fall in LVEF
Sensitivity/specificity same as nuclear
testing
May be better in women
Stress Echo vs. Nuclear Stress
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
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
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
Risk Factor Modification
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Hypertension
Smoking
Dyslipidemia
Diabetes Mellitus
Obesity
Stress
Homocysteine
Stable Angina
Treatment Options
Angina
Treatment Options
Medicine
Percutaneous
Intervation
CABG
Stable Angina
Treatment Options
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Medical Treatment
Stable Angina
Current Pharmacotherapy
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Beta-blockers
Calcium channel blockers
Nitrates
Aspirin
Statins
? ACE inhibitors
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
Beta-Blockers
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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
Beta-Blockers
Beta Blockers
Side Effects
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Bronchospasm
Diminished exercise capacity
Negative inotropy
Sexual dysfunction
Bradyarrhythmia
Masking of hypoglycemia
Increased claudication
Hair loss
Beta Blockers
Common Available Agents
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Propranolol
Atenolol
Metoprolol
Nadolol
Timolol
Calcium Channel Blockers
Mechanisms of Action
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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
Calcium Channel Blockers
Mechanisms of Action
Calcium Channel Blockers
Mechanisms of Action
Calcium Channel Blockers
Side Effects
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Palpitations
Headache
Ankle edema
Gingival hyperplasia
Calcium Channel Blockers
Available Agents
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Verapamil
Diltiazem
Nifedipine
Nicardipine
Amlodipine
Felodipine
Nisoldipine
Bepridil
Stable Angina
Treatment Options
Nitrates
Mechanisms of Action
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Nitric oxide has been identified as
endothelium-derived relaxing factor
Organic nitrates are therapeutic precursors
of endothelium-derived relaxing factor
Nitrates
Mechanisms of Action
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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
Nitrates
Reducing Tolerance
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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
Nitrates
Side Effects
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Headache
Flushing
Palpitations
Tolerance
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To provide optimal benefit to patients,
clinicians must use nitroglycerin more
systematically and critically than they have
before
W. Frischman
Nitrates
Common Available Agents
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Isorbide dinitrate
Isorbide mononitrate
Long-acting transdermal patches
Nitroglycerin sl
Stable Angina
Treatment Options
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CABG
Stable Angina
Results of CABG
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65% remain symptom-free at ten years
85% remain free of fatal/nonfatal MI at ten
years
Mortality of 2-3% yearly over ten years
2.5% incidence of perioperative MI
CABG vs. Medical Rx
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Three major randomized trials
A. VACS
B. ECSS
C. CASS
Improved mortality in CABG group
A. L-main CAD
B. 3-vessel CAD, esp. with decreased EF
C. LAD disease, severe angina, decreased EF
Stable Angina: CABG
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“Nevertheless, bypass grafting remains a
palliative procedure, as is every known
treatment for coronary disease, and it assure
permanent freedom neither from symptoms
nor from a fatal coronary event…”
Hull R. Tex Hrt Jnl 1989;16:127-129
Stable Angina
Treatment Options
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PTCA
PTCA vs. Medical Management
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Review of six major trials
Greater symptomatic benefit in PTCA group
No change in mortality or rates of MI
Higher rate of CABG in PTCA group
BMJ 2000(Jul);321:73-77.
PTCA vs Medical Management
Multivessel Disease
Stable Angina
Results of PTCA
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80% or greater success rate
1% mortality
3-5% emergency CABG ( prior to stenting )
4% acute MI
CABG vs PTCA
Multivessel Disease
• Review of six major randomized trials
• Most patients had preserved LVEF
• No differences in mortality or combined endpoint
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of death and nonfatal MI
Second revascularization procedure more likely in
first year after PTCA
Surgery patients more likely to be angina free at
one year
CABG vs. PTCA
Multivessel Disease
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Most patients had 2-vessel CAD, preserved
LVEF, and “suitable” anatomy
CABG vs. PTCA
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BARI Trial Subset of Diabetic Patients
A. Five-year survival better in CABG group
B. Increased incidence of MI at eight years
C. More women, hypertension, CHF, and severe
concomitant noncardiac disease
D. More multi-vessel disease, significant
lesions, and distal lesions
Stable Angina: 1-Vessel CAD
Therapeutic Strategies
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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
Stable Angina: 2-Vessel CAD
Therapeutic Strategies
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Initial medical management in patients with mild
ischemic symptoms and normal LV function
Revascularization in patients who fail medical
therapy
Selection of PTCA vs. CABG depends on
coronary anatomy, LV function, need for
complete revascularization, and patient
preference
Stable Angina: 3-Vessel CAD
Therapeutic Strategies
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CABG in patients with left-main disease or
3-vessel CAD and decreased LVEF
PTCA or medical management an
alternative in patients with 3-vessel CAD,
mild symptoms, and preserved LVEF
Chronic Angia: Reading List
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Gersh BJ, Solomon AJ. Management of
chronic stable angina: medical therapy,
PTCA, and CABG. Ann Internal Med
1998(FEB);128:216-223.