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MANAGEMENT OF STABLE ANGINA- THE BASICS
Dr Jayachandran Thejus
Coronary artery disease- Block in coronary
artery due to plaque or thrombus
Leads to myocardial ischemia manifested as chest discomfort
Two types- Plaque- stable angina Thrombus- acute
coronary syndrome
Stable angina- Obstructive plaque Blood flow enough at
rest Blood flow is
inadequate when heart muscle needs extra blood as during exercise or emotional stress
Angina on exertion or emotion
Stable angina means exertional chest discomfort due to a fixed stenosis in a coronary artery.
How to diagnose whether a person with chest discomfort has coronary artery disease or not? Assess the
probability Typical nature
of pain Age Male sex Risk factors
Low probability- no tests
Intermediate probability- TMT or alternate tests
High probability- coronary angiography
Intermediate probability- which test to choose?
Treadmill exercise test or TMT
TMT is not possible Pt cannot exercise LBBB, WPW, pacemaker, resting ST
depression, digitalis SPECT CT angiography
SPECT
Radioactive technitium is injected IV at stress and at rest
Radioactivity from various areas of the heart is measured.
Perfusion defect during stress indicates ischemic myocardium.
Can be done with adenosine IV in patients who cannot exercise
CT coronary angiography
Negative predictive value is high.
Positive predictive value is low.
Useful to rule out CAD in low risk patients.
If positive, does not mean that stenosis is present. ICA is needed.
Invasive coronary angiography- Intermediate probability- Stress test
positive High probability
Typical angina RWMA by echo Low EF by echo
Patient presents with chest pain. You evaluate the patient and find the
probability of having CAD. Low probability- follow-up. Intermediate probability- TMT. If
positive- angiography. High probability- angiography
Angiography- No plaques- no
treatment Non-obstructive
coronary plaques- medical management
Obstructive coronary plaques- Small vessel- Medical
management Large vessel- PCI or
CABG
Coronary stenosis- Single vessel- PCI Multivessel- SYNTAX score
<22- PCI 22 to 32- PCI or CABG >/= 33-CABG
Left main- Ostial or mid- PCI Distal- CABG
Lifestyle modification
Smoking cessation Most effective lifestyle change Nicotine gum and bupropion can be
given Diet
Decrease saturated fatty acids Increase PUFA- fish Increase fruit and vegetable intake Decrease total energy intake to keep BMI
< 25
Regular physical activity Aerobic activity like walking is preferred Intensity depends on cardiac status
Sexual activity PDE5 inhibitor has interaction with
nitrates Weight reduction Sleep apnoea evaluation
LDL Reduce by > 50%
BP Keep < 140/90 mm Hg
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Aspirin 75 to 150 mg/day.
If intolerant, clopidogrel.
Do not add aspirin to clopidogrel.
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Statin always needs to be added.
LDL has to be reduced by more than 50% of basline value.
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
ACEI to improve prognosis in HT DM CKD EF 40% or less
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Sublingual nitrate SOS 5 mg ISDN 0.5 mg NTG
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Beta-blocker Any cardioselective
beta-blocker Do not combine
with non-DHP Ca CB Include to improve
prognosis in post MI and HF.
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
CaCB Non-DHP
Verapamil Diltiazem
DHP Long acting nifedipine Amlodipine
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Long acting nitrate If frequent angina 10 mg ISDN TDS or
30 – 60 mg ISMN bid or controlled release NTG 2.6 or 6.4 mg bid
Try to avoid CaCB or alpha blocker
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Ranolazine 500 to 1000 mg bid Most trial data
among alternative drugs
No effect on BP or heart rate
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Ivabradine 5 to 7.5 mg bid If rate is
uncontrolled even after b B optimum dose
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Nicorandil 5 to 10 mg bid
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
Trimetazidine 35 mg bid
Pharmacological treatment- To improve long term
prognosis Aspirin Statin
To relieve angina S/L nitrate SOS If angina is frequent- b
B or Ca CB or both Is still no relief- long
acting nitrate or other drugs
EECP Spinal cord
stimulation Chelation
THANK YOUYou can download the slide set at heartpearls.com