1. Angina pectoris
Domina Petric, MD

2. Introduction Angina pectoris (AP) is due to myocardial ischaemia.
AP presents as a central chest tightness or heaviness.
Symptoms are brought on by exertion and relieved by rest.

3. Pain may radiate to one or both arms, the neck, jaw or teeth.
Introduction
Pain may radiate to one or both arms, the neck, jaw or teeth.

4. Precipitating factors
physical exertion
emotion
cold weather
heavy meals

5. Associated symptoms
dyspnoea
nausea
sweatiness
faintness

6. Causes aortic stenosis tachyarrhythmias hypertrophic cardiomyopathy
atherosclerosis, atheroma
anemia
aortic stenosis
tachyarrhythmias
hypertrophic cardiomyopathy
arteritis or small vessel disease (microvascular angina, cardiac syndrome x)

7. Types of angina Stable angina is induced by effort, relieved by rest.
Unstable (crescendo) angina is angina that is of increasing frequency or severity and occurs on minimal exertion or at rest.
Unstable angina is associated with high risk of myocardial infarction.

8. Types of angina Decubitus angina is precipitated by lying flat.
Variant (Prinzmetal´s angina) is caused by coronary artery spasm.
Prinzmetal´s angina may co-exist with fixed stenosis.

9. Stable angina Lumen of blood vessel is narrowed by plaque.
There is inappropriate vasoconstriction.

10. Unstable angina Plaque is ruptured. There is platelet aggregation.
Thrombus formation!
Unopposed vasoconstriction!

11. Variant angina No overt plaques. Intense vasospasm!
Prognosis is very good.
No overt plaques.
Intense vasospasm!

12. Prinzmetal angina
This is due to coronary artery spasm which can occur even in normal coronary arteries.
Pain occurs during rest rather than during activity.
ECG: ST segment elevation.
ST segment elevation is present during pain, but usually resolves as the pain subsides.

13. Tranzient ST elevation during pain in Prinzmetal´s angina.
Image source: WIKIWAND
Tranzient ST elevation during pain in Prinzmetal´s angina.

14. Prinzmetal angina
Treatment: calcium channel blockers with or without long-acting nitrates.
Aspirin can aggravate the ischaemic attacks in these patients.
Beta-blockers should be avoided because they can increase vasospasm.

15. ECG in stable angina It is usually normal.
There may be ST depression, flat or inverted T waves, eventually signs of past myocardial infarction.

17. ST depression
Planar (horizontal) or down-sloping ST segment depression of one millimeter or more is indicative of ischemia.
Up-sloping ST segment depression is less specific and it is often found in normal heart.

18. anaemia diabetes hyperlipidaemia thyrotoxicosis temporal arteritis
It is very important to exclude precipitating factors during diagnostics of AP:
anaemia
diabetes
hyperlipidaemia
thyrotoxicosis
temporal arteritis

19. II.
management

20. Modifying risk factors
smoking cessation
weight loss
moderate exercise
lowering arterial blood pressure
control of blood sugar and lipemia

21. Aspirin
Aspirin in dose mg a day can reduce mortality rate by 34%. Aspirin is contraindicated in Prinzmetal angina.

22. Beta-blockers
Atenolol (for example) mg a day per os can reduce symptoms.
BB are contraindicated in asthma, COPD, left ventricular failure, bradycardia and coronary artery spasm (like in variant angina).

23. Nitrates
Spray or sublingual tablets up to every half an hour for symptoms relief.
Nitrates can be used for prophylaxis: isosorbide mononitrate mg per os twice a day.
It is very important to achieve an 8 hours nitrate free period to prevent tolerance.

24. Nitrates
Alternative for prophylaxis are slow-release nitrates, adhesive nitrate skin patches and buccal pills.
Common nitrates side effects are headaches and hypotension.
Nitrates are contraindicated if blood pressure is below 90/60 mmHg.

25. Long acting calcium antagonists
Amplodipine 10 mg/24 h
Diltiazem mg/12 h

26. Ivabradine Ivabradine inhibits the pacemaker current in the SA node.
Ivabradine reduces heart rate.
It can be usefull in patents that can not take beta blockers for some reason.

27. Other drugs Trimetazidine inhibits fatty acid oxidation.
Ranolazine inhibits the late sodium current.
Nicorandil is potassium channel activator.

28. Indications for hospital admission
new angina of sudden onset
recurrent angina in patients with past myocardial infarction or CABG
angina uncontrolled by drugs
unstable angina

29. Percutaneous transluminal coronary angioplasty (PTCA)
PTCA involves balloon dilatation of the stenotic vessels.

30. Indications for PTCA poor response or intolerance to medical therapy
refractory angina in patients not suitable for CABG
previous CABG
post-thrombolysis in patients with severe stenoses, symptoms or positive stress tests

31. Benefits of PTCA
Early intervention may benefit high risk patients presenting with non-ST segment elevation myocardial infarction.
Stenting reduces restenosis rates.

32. restenosis (20-30% within 6 months) emergency CABG (<3%)
Complications of PTCA
restenosis (20-30% within 6 months)
emergency CABG (<3%)
myocardial infarction (<2%)
death (<0,5%)

33. Thrombosis prevention
Antiplatelet agents (clopidogrel) reduce the risk of stent thrombosis.
Iv. glycoproteins IIb/IIIa inhibitors (eptifibatide) reduce procedure-related ischaemic events.
Drug-coated stents reduce restenosis rate, but increase risk of late in-stent thrombosis.

34. Literature:
Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition.
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