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
Not new exacerbated
3
Chest pain caused by transient
myocardial ischemia due to an
imbalance between myocardial
oxygen supply and demand.
4
Clinical Manifestations
Myocardial Blood Flow
Myocardial O2 Demands
Differential Diagnosis of Chest Pain
Transient Myocardial
ischemia
Fixed threshold angina
Severe Chest pain
Variable threshold angina
• FIXED-THRESHOLD= Angina Caused by
Increased Myocardial O2 Requirements
• VARIABLE-THRESHOLD = Angina Caused by
Transiently Decreased O2 Supply
• MIXED ANGINA.
Differential Diagnosis of Chest
Pain
Physical Examination
Pathophysiology
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
Resting Electrocardiogram
50% between attacks : ECG is entirely
Other : old problems
50% durig pain = NL-ECG
NORMAL
Noninvasive Stress Testing
Anginal pain is often associated with Depression
of ST segment
Exercise ECG showing typical severe down sloping ST
segment :
Standing
1 min.
3 min.
7 min.
9 min.
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• Computed Tomography (MSCT):
90%=sensitivity 50% = specificity
• Cardiac Magnetic Resonance Imaging
Catheterization, Angiography, and
Coronary Arteriography
• SVD = 2VD = 3VD = 25%.
• LML = 5 – 10%.
• NL-CAG = 15%.
diffuse disease than MI
Natural History of Angina
Pectoris and Risk Stratification
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
General measures
Treat Hypertension ,
Hypercholestrolimia
and Diabetes
Stop smoking
AVOID
Severe
exertion
Reduce weight
Heavy meal
Emotions
Cold Weather
•Graduated exercise may open new collaterals
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Treatment of an acute attack of angina
Sublingual nitroglycerin (0.5 mg ) or isosorbide
dinitrate (5 mg ) or
Oral spray nitroglycerin (0.4 mg/metered dose),
isosorbide dinitrate(1.25 mg/metered dose)
Persistence of pain
Relief within 1-3 min.
Repeat nitroglycerin at 5 min.
interval (3 tab. max.)
Relief
HOSPITALIZATION
not relieved
Infarction
What are the antianginal drugs?
Organic nitrates.
- adrenoceptor blockers.
Calcium channel blockers.
?
?
?
?
Anti-platelet
• ASPIRIN
• CLOPIDOGREL
Rx for Risk factors
• HTN
• DM
• HLP
- statins
• ACE-Inh:
Management of Variant Angina
Nitrates and/or Ca- Channel
blockers
For the acute attack & prophylaxis
Beta-Blocker?
ASA?
For patients not responding to adequate medical
therapy:
•Percutaneous Transluminal coronary
Angioplasty (PTCA)
•Coronary artery bypass grafting (CABG)
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