1. Management of Stable Angina Pectoris David Putnam, MD Albany Medical College

2. 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.

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. CCSC Angina Classification Class I 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 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

18. Angina: Exercise Testing Low Risk Group CASS Registry: 7 year survival Less than 1 mm ST depression in Stage III of Bruce Protocol Annual mortality: 1.3% JACC 1986;8:741-8

19. ECG Treadmill EST 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 EST Diagnosis/prognosis for CAD Non-diagnostic EST Abnormal resting ECG Negative EST with continued chest pain Intermediate probability of disease

21. Stable Angina Guidelines for Nuclear EST Defined CAD Post infarct risk stratification Risk stratification to determine need for revascularization ( viability study )

22. Stable Angina Dipyridamole Nuclear EST Near equivalent sensitivity/specificity with symptom-limited nuclear EST Most useful in patients who cannot exercise Major contraindication is severe bronchospastic lung disease ( consider Dobutamine study )

23. Appropriateness of Radionuclide Exercise Testing Retrospective analysis of 1092 patients 64% of tests ordered by cardiologists were indicated 30% of tests ordered by non-cardiologists were indicated Excessive charges from non-indicates tests were $1,082,400 Am J Card 1996;77:139-42

24. 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

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

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

30. Medical Treatment

31. Stable Angina Current Pharmacotherapy Beta-blockers Calcium channel blockers Nitrates Aspirin Statins ? ACE inhibitors

32. 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

33. 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

34. Beta-Blockers

35. Beta Blockers Side Effects Bronchospasm Diminished exercise capacity Negative inotropy Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia Increased claudication Hair loss

36. Beta Blockers Common Available Agents Propranolol Atenolol Metoprolol Nadolol Timolol

37. 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

38. Calcium Channel Blockers Mechanisms of Action

40. Calcium Channel Blockers Side Effects Palpitations Headache Ankle edema Gingival hyperplasia

41. Calcium Channel Blockers Available Agents Verapamil Diltiazem Nifedipine Nicardipine Amlodipine Felodipine Nisoldipine Bepridil

42. Nitrates Mechanisms of Action Nitric oxide has been identified as endothelium-derived relaxing factor Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

43. 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

44. 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

45. Nitrates Side Effects Headache Flushing Palpitations Tolerance

46. To provide optimal benefit to patients, clinicians must use nitroglycerin more systematically and critically than they have before W. Frischman

47. Nitrates Common Available Agents Isorbide dinitrate Isorbide mononitrate Long-acting transdermal patches Nitroglycerin sl

48. Stable Angina Treatment Options CABG

49. Stable Angina Treatment Options PTCA

50. 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

51. 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

52. 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