1. Chronic stable angina Dr Taban Internist & cardiologist

2. MAGNITUDE OF THE PROBLEM Lifetime risk of CAD after 40Y: Men = 49% Women =32% 52% cardiac death One of six all death

3. Stable Angina. Not new onset Not at rest chest pain The commonest cause isADVANCED ATHEROSCELEROSIS The commonest cause is ADVANCED ATHEROSCELEROSIS Not new exacerbated 3

4. Chest pain caused by transient myocardial ischemia due to an imbalance between myocardial oxygen supply and demand. Chest pain caused by transient myocardial ischemia due to an imbalance between myocardial oxygen supply and demand. 4

5. Transient Myocardial ischemia Severe Chest pain Myocardial Blood Flow Myocardial O2 Demands Fixed threshold angina Variable threshold angina Clinical Manifestations Differential Diagnosis of Chest Pain

6. FIXED-THRESHOLD= Angina Caused by Increased Myocardial O2 Requirements VARIABLE-THRESHOLD = Angina Caused by Transiently Decreased O2 Supply MIXED ANGINA.

8. Differential Diagnosis of Chest Pain

9. Physical Examination

10. Pathophysiology

11. 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

12. Resting Electrocardiogram 50% durig pain = NL-ECG 50% between attacks :ECG is entirely entirely NORMAL Other : old problems

13. Exercise ECG showing typical severe down sloping ST segment : Anginal pain is often associated with Depression of ST segment Standing 1 min. 3 min. 7 min. 9 min. Noninvasive Stress Testing 13

15. Computed Tomography (MSCT): 90%=sensitivity 50% = specificity Cardiac Magnetic Resonance Imaging

16. Catheterization, Angiography, and Coronary Arteriography SVD = 2VD = 3VD = 25%. LML = 5 – 10%. NL-CAG = 15%. diffuse disease than MI

17. Natural History of Angina Pectoris and Risk Stratification

19. 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

20. Stop smoking Reduce weight Treat Hypertension, Hypercholestrolimia and Diabetes AVOIDSevereexertion Heavy mealEmotionsCold Weather General measures 20 Graduated exercise may open new collaterals

21. Treatment of an acute attack of angina Sublingual nitroglycerin (0.5 mg ) or isosorbide dinitrate (5 mg ) 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) Relief within 1-3 min. Persistence of pain Repeat nitroglycerin at 5 min. interval (3 tab. max.) Relief not relieved Infarction HOSPITALIZATION

22. What are the antianginal drugs? Organic nitrates. Calcium channel blockers.  - adrenoceptor blockers.

23.  -blocker + Long acting Nitrate  -blocker + Nifedipine/amilodipin Verapamil or Diltiazem + Nitrate  -blocker + Nitrate + Nifedipine/amilodipin ???? ???? ???? ????

24. Anti-platelet ASPIRIN CLOPIDOGREL

25. Rx for Risk factors HTN DM HLP - statins

26. ACE-Inh:

27. Management of Variant Angina Nitrates and/or and/or Ca- Ca- Channel blockers For the acute attack & prophylaxis Beta-Blocker? ASA?

28. For patients not responding to adequate medical therapy: PercutaneousPercutaneous Transluminal coronary Angioplasty (PTCA) CoronaryCoronary artery bypass grafting (CABG) 28

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