1. 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.

2. ANGINA

3. STABLE ANGINA CLASSIFICATION
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 ANGINA EVALUATION OF LV FUNCTION
Physical exam.
CXR.
Echocardiogram.

14. STABLE ANGINA EVALUATION OF ISCHEMIA
History.
Baseline Electrocardiogram.
Exercise Testing.

15. CCS ANGINA CLASSIFICATION
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.

16. STABLE ANGINA EXERCISE TESTING
The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation.

17. ANGINA: EXERCISE TESTING

18. ANGINA: EXERCISE TESTING HIGH 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.

19. ECG TREADMILL TEST 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 ANGINA GUIDELINES FOR NUCLEAR TEST
Diagnosis/prognosis for CAD.
Non-diagnostic TEST.
Abnormal resting ECG.
Negative TEST with continued chest pain.
Intermediate probability of disease.

21. STABLE ANGINA GUIDELINES FOR NUCLEAR TEST
Defined CAD.
Post infarct risk stratification.
Risk stratification to determine need for
revascularization ( viability study ).

22. STABLE ANGINA DIPYRIDAMOLE NUCLEAR TEST
Near equivalent sensitivity/specificity with symptom-limited nuclear TEST.
Most useful in patients who cannot exercise.
Major contraindication is severe bronchospastic lung disease ( consider Dobutamine study ).

23. STABLE ANGINA STRESS ECHO
Ischemia may cause wall motion abnormalities, no rise of fall in LVEF.
Sensitivity/specificity same as nuclear testing.
May be better in women.

24. STRESS ECHO VS. NUCLEAR STRESS

25. EXERCISE TESTING CONTRAINDICATIONS
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 ANGINA NON-INVASIVE EVALUATION
Non disabling Angina
Resting LV Functions
LV dysfunction
Normal LV function
Coronary Angiography
Stress Test
High Risk
Low Risk
Coronary Angiography
Medical Therapy
Stable
Recurrent Angina
Medical Therapy
Coronary Angiography

27. CARDIAC CATHETERIZATION INDICATIONS
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 ANGINA TREATMENT OPTIONS
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Angina Treatment Option
Percutaneous Intervention
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Medicine
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CABG

30. STABLE ANGINA MEDICAL TREATMENT
Beta-blockers
Calcium channel blockers
Nitrates
Aspirin
Statins
? ACE inhibitors

31. STABLE ANGINA CONSIDERATIONS WHEN CHOOSING A DRUG
Effect on myocardium
Effect on cardiac conduction system
Effect on coronary/systemic arteries
Effect on venous capitance system
Circadian rhytm

32. 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

33. BETA-BLOCKERS

34. BETA BLOCKERS SIDE EFFECTS
Bronchospasm
Diminished exercise capacity
Negative inotropy
Sexual dysfunction
Bradyarrhythmia
Masking of hypoglycemia
Increased claudication
Hair loss

35. BETA BLOCKERS COMMON AVAILABLE AGENTS
Propranolol
Atenolol
Metoprolol
Nadolol
Timolol

36. CALCIUM CHANNEL BLOCKERS MECHANISMS 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

37. CALCIUM CHANNEL BLOCKERS MECHANISMS OF ACTION

38. CALCIUM CHANNEL BLOCKERS MECHANISMS OF ACTION

39. CALCIUM CHANNEL BLOCKERS SIDE EFFECTS
Palpitations
Headache
Ankle edema
Gingival hyperplasia

40. CALCIUM CHANNEL BLOCKERS AVAILABLE AGENTS
Verapamil
Diltiazem
Nifedipine
Nicardipine
Amlodipine
Felodipine
Nisoldipine
Bepridil

41. NITRATES MECHANISMS OF ACTION
Nitric oxide has been identified as endothelium-derived relaxing factor
Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

42. NITRATES MECHANISMS 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

43. NITRATES REDUCING 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. NITRATES SIDE EFFECTS
Headache
Flushing
Palpitations
Tolerance

45. NITRATES COMMON AVAILABLE AGENTS
Isorbide dinitrate
Isorbide mononitrate
Long-acting transdermal patches
Nitroglycerin SL

46. STABLE ANGINA TREATMENT OPTIONS
CABG
PTCA

47. STABLE ANGINA: 1-VESSEL CAD THERAPEUTIC 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

48. STABLE ANGINA: 2-VESSEL CAD THERAPEUTIC STRATEGIES
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

49. STABLE ANGINA: 3-VESSEL CAD THERAPEUTIC STRATEGIES
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