1 3 rd jan 2009 done by: ahmed m. aljabri pharm.d
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3rd jan 2009
Done by: Ahmed M. Aljabri Pharm.D
Angina Overview Pathophysiology Types of angina Diagnosis Management Key points
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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
This usually happens because one or more of the heart's arteries is narrowed or blocked
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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 :
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
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 :
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
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1. Stable angina
2. Unstable angina
3. Variant (Prinzmetal's) angina
Knowing how the types are different is important
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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
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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
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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
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Differential Diagnosis of Episodic Chest Pain
Person's medical history and risk factors
Chest X-ray
Electrocardiogram (ECG)
Echocardiography
Cardiac enzymes to role out myocardial infarction
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The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%
It’s the most accurate test to detect arterial coronary narrowing
Acute myocardial infarction (heart attack)
Severe cardiac arrhythmias
Cardiac arrest leading to sudden death
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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
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Lifestyle changes
Medicines
Medical procedures
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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
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medications used to treat angina address the myocardial oxygen demand/supply imbalance from a hemodynamic perceptively
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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
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 minspray preparation where each “puff” is 0.4 mg
Nitroglycerin intravenous infusion5-200 micro gm/min; short action require continuous infusion
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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
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
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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
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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 muscleReducing muscle oxygen demand
Calcium channel blockers is the drug of choice in variant angina
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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
durationMiscellaneous; 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
Treatment of choice ; is sublingual nitroglycerin. This therapy is effective for stable, unstable, or variant angina
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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
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
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
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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
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.
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
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
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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
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• http://www.americanheart.org/presenter.jhtml?identifier=4472
• Joseph T. et-al, PHARMACOTHERAPY, McGraw-Hill Inc., 6th Edition, 2005, Chapter 15, pg.297-320
Leon S.et al, comprehensive pharmacy review, the point inc, 6th Edition,2007,chapter 39,page 786-812.
www.uptodate.com.uptodate 16.3
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