1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Angina Pectoris N.A.N 2009 Presented by: Nasrullah Medical Student February 2009

3. Objective Definition of angina. Types of angina. Classification of angina. Causes. Most risk factors. Investigation. Treatment in general. Summury. N.A.N 2009

4. Definition of Angina Pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. Angina pectoris is more often the presenting symptom of coronary artery disease in women than in men. Increase with age N.A.N 2009

5. Types of angina 1. Stable angina. 2. Unstable angina N.A.N 2009

6. Stable angina is that occurs when coronary perfusion is impaired by fixed or stable atheroma of coronary arteries. Ex. Pt. has fixed capacity of exertion after he starts feeling chest pain.

7. Unstable angina is that characterized by rapidly worsening chest pain on minimal exertion or at rest. = ulcerated atheroma+ thrombus formation>>> reduction of coronary blood flow caused by thrombus>> angina at rest

8. Unstable angina Recent onset (less than 1 month). Increase frequency and duration of episode. Angina at rest not responding readily to therapy. If the pain more than 30 min.???? MI

9. Stable Angina Classification Exertional Variant or Prinzmetal’s Angina Anginal Equivalent Syndrome Syndrome-X Silent Ischemia Decubitus angina Noctural angina N.A.N 2009

10. Exertional or classical It occurs due to increase myocardial oxygen demand during exertion or emotion in a patient of narrow coronary arteries. It relieved by rest and nitroglycerine. Coronary artery obstructions are not sufficient to result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results. N.A.N 2009

11. Variant or Prinzmetal’s 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 N.A.N 2009

12. Prinzmetal’s Angina Spasm of a large coronary artery Transmural ischemia ST-Segment elevation at rest or with exercise More prolonged than in classical angina. It occurs more in women under age 50. N.A.N 2009

13. Anginal Equivalent Syndrome Patient’s with exertional dyspnea rather than exertional chest pain Caused by exercise induced left ventricular dysfunction N.A.N 2009

14. 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 N.A.N 2009

15. Silent Ischemia Very common More episodes of silent than painful ischemia in the same patient Difficult to diagnose Holter monitor Exercise testing N.A.N 2009

16. Holter monitor N.A.N 2009

17. Decubitus angina Occurs when pt. lies down. Usually ass. With impaired LV function. Pt usually has severe CAD when pt, has these symptoms, N.A.N 2009

18. Noctural angina It awakes the pt. from sleep, It may provoked by vivid dreams. It may occur due to CAO or coronary spasm N.A.N 2009

19. The Canadian Cardiovascular Society grading scale is used for classification of angina severity, as follows: Class I : Angina only during strenuous or prolonged physical activity Class II : Slight limitation, with angina only during vigorous physical activity Class III : Symptoms with everyday living activities, ie, moderate limitation Class IV : Inability to perform any activity without angina or angina at rest, ie, severe limitation N.A.N 2009

20. The New York Heart Association classification is also used to quantify the functional limitation imposed by patients' symptoms, as follows: 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 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.) N.A.N 2009

21. Causes: Decrease in myocardial blood supply due to increased coronary resistance in large and small coronary arteries: 1. Significant coronary atherosclerotic lesion in the large epicardial coronary arteries (ie, conductive vessels) with at least a 50% reduction in arterial diameter 2. Coronary spasm (ie, Prinzmetal angina) 3. Abnormal constriction or deficient endothelial-dependent relaxation of resistant vessels associated with diffuse vascular disease (ie, microvascular angina) 4. Syndrome X 5. Systemic inflammatory or collagen vascular disease, such as scleroderma, systemic lupus erythematous, Kawasaki disease, polyarteritis nodosa, and Takayasu arteritis N.A.N 2009

22. Cause cont. Increased extravascular forces, such as severe LV hypertrophy caused by hypertension, aortic stenosis, or hypertrophic cardiomyopathy, or increased LV diastolic pressures Reduction in the oxygen-carrying capacity of blood, such as elevated carboxyhemoglobin or severe anemia (hemoglobin, <8 g/dL) Congenital anomalies of the origin and/or course of the major epicardial coronary arteries N.A.N 2009

23. Causes cont. Structural abnormalities of the coronary arteries 1. Congenital coronary artery aneurysm or fistula 2. Coronary artery ectasia 3. Coronary artery fibrosis after chest radiation 4. Coronary intimal fibrosis following cardiac transplantation N.A.N 2009

24. Risk factors: Major risk factors for atherosclerosis: like family history of premature CAD, cigarette smoking,DM,hypercholesterolemia(Metabolic syndrome), or systemic HTNatherosclerosisMetabolic syndrome Other risk factors: These include LV hypertrophy, obesity, N.A.N 2009

25. Precipitating factors: These include factors such as severe anemia, fever, tachyarrhythmias, catecholamines, emotional stress, and hyperthyroidism, which increase myocardial oxygen demand. N.A.N 2009

26. Preventive factors: Factors associated with reduced risk of atherosclerosis are a high serum HDL cholesterol level, physical activity, estrogen, and moderate alcohol intake (1- 2 drinks/d). ???!! Plz Don’t drink and smoke 4u life. N.A.N 2009

27. Stable Angina Evaluation of LV Function Physical exam CXR Echocardiogram N.A.N 2009

28. Stable Angina Evaluation of Ischemia History Baseline Electrocardiogram Exercise Testing N.A.N 2009

29. 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 N.A.N 2009

30. ECG ST segment depression with or without T wave inversion that reverse after ischemia disappears. N.A.N 2009

31. ECG Elevation of ST segment in prinzmental’s angina. N.A.N 2009

32. ECG The resting ECG may be normal between attacks however it may show old MI, heart block or LVH N.A.N 2009

33. Stable Angina Exercise Testing The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation N.A.N 2009

34. 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 N.A.N 2009

35. 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 N.A.N 2009

36. 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 N.A.N 2009

37. Stable Angina Stress Echo Ischemia may cause wall motion abnormalities, no rise of fall in LVEF ( left ventricular ejection fraction ) This formula gives one a fraction, e.g., 0.60. Multiply this fraction by 100 gives a % figure, e.g., 60% Sensitivity/specificity same as nuclear testing N.A.N 2009

38. 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 percutaneous transluminal coronary angioplasty coronary artery bypass grafting N.A.N 2009

39. Angina: Treatment Goals Feel better Live longer N.A.N 2009

40. Stable Angina Treatment Options N.A.N 2009

41. Stable Angina Non-Invasive Evaluation N.A.N 2009

42. Stable Angina Treatment Options Medical Treatment N.A.N 2009

43. Stable Angina Current Pharmacotherapy Beta-blockers Calcium channel blockers Nitrates Aspirin Statins ? ACE inhibitors N.A.N 2009

44. 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 N.A.N 2009

45. Reference Medical diagnosed and mangement 8 th 2006,mohammed Danish OHCM 7 th 250 cases in clinical examination. pocket clincal medicine 3nd. Kumar & Clark http://www.ncbi.nlm.nih.gov/ http://emedicine.medscape.com/article/150215-overview http://www.heartfailurematters.org http://health.allrefer.com/ Ect….. N.A.N 2009

46. THANKS 4 HEARING MY PRESENTATION I hope that it is useful My best regards NASRULLAH NASRULLAH (N.A.N)