1. ANGINA PECTORIS

2. Angina pectoris (chest pain) is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand

3. Epidemiology of angina pectoris Epidemiology of angina pectoris: Approximately 9.8 million Americans are estimated to experience angina annually, with 500,000 new cases of angina occurring every year. Mortality/Morbidity: About every 25 seconds, an American will have a coronary event, and about every minute someone will die from one.

4. ETIOLOGY OF ANGINA PECTORIS The main causes of angina pectoris are atherosclerosis of the coronary arteries spasm

5. Major risk factors for angina include cigarette smoking, cigarette smoking, diabetes, diabetes, high cholesterol, high cholesterol, high blood pressure, high blood pressure, sedentary lifestyle, sedentary lifestyle, family history of premature heart disease. family history of premature heart disease.

6. The New York Heart Association classification Class I - No limitation of physical activity (Ordinary physical activity does not cause symptoms.) Class I - No limitation of physical activity (Ordinary physical activity does not cause symptoms.) Class II - Slight limitation of physical activity (Ordinary physical activity does cause symptoms.) Class II - Slight limitation of physical activity (Ordinary physical activity does cause symptoms.) Class III - Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.) Class III - Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.) Class IV - Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest.) Class IV - Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest.) Unstable angina is defined as new-onset angina (ie, within 2 mo of initial presentation) of at least class III severity, significant recent increase in frequency and severity of angina, or angina at rest.

7. Symptomsand signs Symptoms and signs Angina is usually felt as: pressure, pressure, heaviness, heaviness, tightening, tightening, squeezing, or squeezing, or aching across the chest, particularly behind the breastbone. aching across the chest, particularly behind the breastbone. Angina is precipitated by exertion, eating, exposure to cold, or emotional stress.

8. Symptomsand signs Symptoms and signs This pain often radiates to the  neck,  jaw,  arms,  back,  or even the teeth. Angina lasts a few minutes (1-5 minutes)

9. TREATMENT OF ANGINA PECTORIS The main goals of treatment in angina pectoris are  to relieve the symptoms,  slow the progression of disease,  and reduce the possibility of future events, especially MI and premature death.

10. TREATMENT OF ANGINA PECTORIS Modification of risk factors (smoking, BP, lipids) Beta blockers Nitroglycerin Calcium channel blockers ACE Inhibitors Antiplatelet drugs Statins The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

11. PHARMACOTHERAPY OF ANGINA PECTORIS Nitroglycerin is a potent smooth-muscle relaxant and vasodilator. Nitroglycerin Sublingual Nitroglycerin is given for an acute attack or for prevention before exertion. 0.3–0.6 mg q 4–5 min up to 3 doses. Dramatic relief usually occurs within 1.5 to 3 min, is complete by about 5 min, and lasts up to 30 min. Nitroglycerin Patients should always carry Nitroglycerin tablets or aerosol spray to use promptly at the onset of an angina attack.

12. Beta-adrenergic blocking agents Reduce myocardial oxygen consumption via several effects, including decrease in resting and exercise heart rates and reductions in myocardial contractility and afterload. Classified as nonselective, beta-1 selective, and having intrinsic sympathomimetic effects.

13. Beta-adrenergic blocking agents Metoprolol. Selective beta1-adrenergic receptor blocker. Initial: 100 mg/day divided q12hr PO, мay be increased at weekly or longer intervals, effective dosage range 100- 400 mg/day PO divided q12hr, no more than 400mg/day. Atenolol. Selectively blocks beta-1 receptors with little or no effect on beta-2 receptors. Dosing and Uses: 50 mg PO qDay; may increase to 100 mg PO qDay after 1 week; some patients may require 200 mg/day.

14. Beta-adrenergic blocking agents Bisoprolol. Selective beta1-adrenergic receptor blocker. Dosing and Uses: 2.5–5 mg po once/day, increasing to 10–15 mg once/day depending on heart rate and BP response. Propranolol. Nonselective beta-blocker. Dosing and Uses: 80-320 mg PO divided q6-12hr. Carvedilol. Nonselective beta-blocker. Dosing and Uses: 25 mg po bid (in patients with heart failure or other hemodynamic instability, the starting dose should be as low as 1.625–3.125 mg bid and increased very slowly as tolerated)

15. Calcium channel blockers Indicated when symptoms persist despite treatment with beta-blockers or when beta-blockers are contraindicated. Amlodipine. Initial: 5-10 mg PO qDay. Diltiazem. Conventional: 30 mg PO q6hr, increase every 1 or 2 days until angina controlled (usually 180-360 mg/day PO divided q6-8hr). Verapamil. Immediate release 80 mg PO q8hr initially; usual range: 80-120 mg PO q8hr; not to exceed 480 mg/day. Extended release: 180 mg/day PO at bedtime initially; maintenance: 180-540 mg/day PO at bedtime.

16. Short-acting nitroglycerins Suitable for immediate relief of exertional or rest angina. Can also be used for prophylaxis several minutes before planned exercise to avoid angina. Nitroglycerin IV. Dosing and Uses: 5 mcg/min, increase by 5 mcg/min q 3-5min up to 20 mcg/min, then increase by 10 mcg/min, may later increase by 20 mcg/min.

17. Long-acting nitroglycerins Long -acting nitroglycerins Isosorbide dinitrate. Initial: 10–20 mg po tid; can be increased to 40 mg tid. Isosorbide dinitrate. Sustained-release capsules. Initial: 40 mg PO, maintenance: 40-80 mg PO q8-12hr. Isosorbide mononitrate 20 mg po bid, with 7 h between 1st and 2nd doses. Isosorbide mononitrate. Sustained-release capsules. 30 or 60 mg once/day, increased to 120 mg or, rarely, 240 mg.

18. Angiotensin-converting enzyme inhibitors ACE Inhibitors have been shown to reduce rates of death, MI, stroke, and need for revascularization procedures in patients with coronary artery disease or diabetes mellitus and at least one other cardiovascular risk factor, irrespective of the presence of hypertension or heart failure. Ramipril. Reduction of Myocardial Infarction/Stroke Risk 2.5-10 mg PO qDay.

19. Antiplatelet drugs Antiplatelet drugs inhibit platelet aggregation. Aspirin. Dosing and Uses: Unstable Angina Pectoris 75-325 mg/day PO. Clopidogrel. Dosing and Uses: Unstable angina 300 mg initial loading dose, follow by 75 mg PO qDay in combination with aspirin 75-325 mg PO qDay. Ticlopidine. Dosing and Uses: 250 mg po bid

20. Anti-ischemic agents, miscellaneous Ranolazine. Cardioselective anti-ischemic agent (piperazine derivative) that partially inhibits fatty acid oxidation. Used in combination with amlodipine, beta- blockers, or nitrates. Treatment of Chronic Angina 500 mg PO BID initially; may increase dose based on clinical symptoms, not to exceed 1000 mg PO BID.

21. Statins Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin

22. Revascularization Revascularization (eg, angioplasty, stenting) should be considered if angina persists despite drug therapy and worsens quality of life or if anatomic lesions (noted during angiography) put a patient at high risk of mortality.