1. 1 3 rd jan 2009 Done by: Ahmed M. Aljabri Pharm.D

2. Main Points Angina  Overview  Pathophysiology  Types of angina  Diagnosis  Management  Key points 2

3.  Angina pectoris is a medical term for chest pain or discomfort due to coronary heart disease  Angina is a symptom of a condition called myocardial ischemia  It occurs when the heart doesn't get as much blood (hence as much oxygen) as it needs

4.  This usually happens because one or more of the heart's arteries is narrowed or blocked 4

5.  Is the single most common cause of premature death in Europe and in 2020 will be the major cause of death in the world  About 1.3 million person with new cases of angina and 330,000 complicated to myocardial infarction every year  Angina occurs in 1:3 men and 1:4 women  It can be a sign of heart disease, even when initial tests don't show evidence of CAD Epidemiology :

6.  Risk factors may include :age, male sex, family history, smoking, alcohol, heavy meals, sedentary life stile, hypertension, obesity, lipid disorders, diabetes mellitus, haemostatic factors and physical inactivity

7.  Typical angina is a pain in the centre of the chest  The discomfort also may be felt in the neck, jaw, shoulder, back or arm Symptom :

8.  Angina often occurs when the heart needs more blood  For example, running to catch a bus could trigger an attack of angina while walking might not  Angina may happen during exercise, strong emotions or extreme temperatures 8

10. 1. Stable angina 2. Unstable angina 3. Variant (Prinzmetal's) angina  Knowing how the types are different is important 10

11.  People with stable angina have episodes of chest pain that are  Usually predictable  Has a regular pattern  Lasting from 0.5 to 30 minutes  It occurs when the heart is working harder than usual  On exertion  Under mental or emotional stress  Normally the chest discomfort is relieved with rest, nitroglycerin or both 11

12.  In people with unstable angina,  Unexpected chest pain  Doesn't follow a pattern  More severe and prolonged than typical angina  It can occur with physical exertion or at rest and may relieved by medicine People with new, worsening or persistent chest discomfort should be evaluated in a hospital emergency department and monitored carefully  Unstable angina is an acute coronary syndrome and should be treated as an emergency 12

13.  Chest pain usually  Occurs spontaneously  Occurs when a person is at rest  Very painful and usually occur between midnight and 8 a.m.  It doesn't follow physical exertion or emotional stress  Variant angina is due to transient coronary artery spasm 13

14. 14 Differential Diagnosis of Episodic Chest Pain

15.  Person's medical history and risk factors  Chest X-ray  Electrocardiogram (ECG)  Echocardiography  Cardiac enzymes to role out myocardial infarction 15

16. Exercise ECG Stress test. Exercise ECG Stress test.  The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%

17.  It’s the most accurate test to detect arterial coronary narrowing

18.  Acute myocardial infarction (heart attack)  Severe cardiac arrhythmias  Cardiac arrest leading to sudden death 18

19. DESIRED OUTCOME(Goals)  The short-term goals of therapy are  To reduce or prevent the symptoms of angina that limit exercise capability and impair quality of life  Long-term goals of therapy are  To prevent CHD events such as MI, arrhythmias, and heart failure and to extend the patient’s life 19

20. Management  Lifestyle changes  Medicines  Medical procedures 20

21. Life style change  Stop smoking and alcohol intake  Physical activities within limits  Avoid large meals and rich foods that leave you feeling stuffed  Control the body weight  Control the blood sugar if the patient is diabetic  Control the blood cholesterol if the patient has a lipid disorder  Avoid stressed  You also can make lifestyle changes that help lower your risk of heart disease

22. 22 Medication;  medications used to treat angina address the myocardial oxygen demand/supply imbalance from a hemodynamic perceptively

23. 23 Treat with drugs Blood supply to the heart Heart's demand for oxygen Coronary vasodilators 1.Nitroglycerin Drugs that reduce blood pressure & Drugs that slow the heart rate 2.Beta-blockers and 3.calcium antagonists

24. Management (1) NG Management (1) NG  1.Short-acting  nitroglycerin tab (0.3-0.6 up to 1.5 mg) Can be repeated at five minute intervals.used in acute attach Can also be used prior to exertion to prevent angina Short term effect;1-7 min  spray preparation where each “puff” is 0.4 mg  Nitroglycerin intravenous infusion5-200 micro gm/min; short action require continuous infusion 24

25.  2. Longer-acting nitroglycerin preparations such as; Isordil tablets 5-80mg, 2-3times daily (Nitro-Dur )transdermal systems (patch form)0.2-0.8mg/hrs every 12 hr. Nitro ointment All relieves spasm of the coronary arteries and can redistribute coronary artery blood flow to areas that need it most Side effect : Headache Flushing Hypotension Management (1) NG

26.  Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart  Decreases the heart rate  Lowers the blood pressure  Reduces the pumping force of the heart muscle All of which reduce the heart muscle's demand for oxygen 26

27. Beta-blockers are the preferred initial choice, often used in conjunction with an organic nitrate to more positively address the hemodynamic imbalances causing the angina Cardio selective beta blocker  Acebutolol : 200-600mg twice daily  Atenolol : 50-200mg/day  Bisoprolol: 10mg/day  Metoprolol: 50-200mg  Nadolol: 40-80mg/day  Propranolol :20-80mg twice daily  Side effects :  Worsening of asthma  Excess lowering of the heart rate and blood pressure  Depression 27

28.  If the patient cannot tolerate the beta-blocker or beta- blocker therapy is contraindicated, a calcium channel blocker with or without an organic nitrate can be considered  Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping force of the heart muscle Reducing muscle oxygen demand  Calcium channel blockers is the drug of choice in variant angina 28

29.  Calcium channel blockers:  Amlodipine :5-10mg OD long duration of action  Felodipine :5-10mg OD long duration of action  Nicardipine : 20-40 mg three times short duration  Nifedipine : immediate release 30-90mg daily short duration  Miscellaneous;  Verapamil.: Immediate release 80-160mg (TDS) short duration {Hypotension,bradycardia, edema, myocardial depression}  Diltiazem :immediate release,30-80mg (QID) {Hypotension,bradycardia, edema } Side effects :  Swelling of the legs  Excess lowering of the heart rate and blood pressure 29

30.  Treatment of choice ; is sublingual nitroglycerin. This therapy is effective for stable, unstable, or variant angina 30

31.  Beta-blockers alone or in conjunction with an organic nitrate  If the beta-blocker therapy is contraindicated or ineffective in preventing angina a calcium channel blocker may be used  Since the combination of a beta-blocker and either verapamil or diltiazem frequently induces undesirable bradycardia  a dihydropyridine is often selected in combination with a beta- blocker  Since stable and unstable angina are nearly always related to coronary artery disease, in addition to anti anginal therapy, patients should be placed on aspirin and, especially if the patient has heart failure or diabetes mellitus

32.  Calcium channel blockers are the preventive treatment of choice for variant angina  Organic nitrates may be added, if needed Beta-blockers are to be avoided since they induce coronary vasospasm

33. Procedures are used to treat angina  Percutaneous transluminal coronary angioplasty  Laser angioplasty and atherectomy  Coronary artery bypass graft surgery Before performing any of these procedures, a doctor must find the blocked part(s) of the coronary arteries 33

34. What's new in diagnosis and management ? What's new in diagnosis and management ?

35.  A newly developed computerized x-ray scan (ultrafast CT scan) is highly accurate in detecting small amounts of calcium in the plaque of coronary arteries  If an ultrafast CT scan shows no calcium in the arteries, atherosclerotic coronary artery disease is unlikely especially in younger age

36.  Coronary arteries can close after angioplasty, causing recurrent angina or even heart attacks  One way to decrease the risk of coronary artery closure is by deploying stents to keep the arteries open  Newer drug-coated stents are being improved to significantly reduce the rate of artery closure.drug-coated stents  Early studies in Europe with Rapamycin-coated stents have resulted in near-zero restenosis rates, which have previously been unprecedented. These stents are now widely available

37.  Angina is one of many causes of chest pain  Angina is chest pain that is a result of inadequate oxygen supply to the heart muscle  Angina can be caused by coronary artery disease or spasm of the coronary arteries 37

38.  ECG, exercise stress test, stress echocardiography, and cardiac catheterization are important in the diagnosis of angina  Treatment of angina includes lifestyle modification, medications, angioplasty, and/or coronary artery bypass surgery 38

39. http://www.americanheart.org/presenter.jhtml?i dentifier=4472 http://www.americanheart.org/presenter.jhtml?i dentifier=4472 Joseph T. et-al, PHARMACOTHERAPY, McGraw- Hill Inc., 6 th Edition, 2005, Chapter 15, pg.297- 320  Leon S.et al, comprehensive pharmacy review, the point inc, 6 th Edition,2007,chapter 39,page 786-812.  www.uptodate.com.uptodate 16.3 www.uptodate.com.uptodate

40. Thank you