chronic stable angina
DESCRIPTION
Chronic stable angina. Dr Taban Internist & cardiologist. MAGNITUDE OF THE PROBLEM . Lifetime risk of CAD after 40Y: Men = 49% Women =32% 52% cardiac death One of six all death. Stable Angina . The commonest cause is ADVANCED ATHEROSCELEROSIS. Not new onset. Not at rest chest pain. - PowerPoint PPT PresentationTRANSCRIPT
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Chronic stable angina
Dr TabanInternist & cardiologist
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MAGNITUDE OF THE PROBLEM Lifetime risk of CAD after 40Y: • Men = 49%• Women =32%
52% cardiac deathOne of six all death
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Stable Angina .
Not new onsetNot new onset
Not at rest chest painNot at rest chest pain
The commonest cause isThe commonest cause is ADVANCED ADVANCED ATHEROSCELEROSISATHEROSCELEROSIS
Not new exacerbatedNot new exacerbated
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Chest pain caused by transient
myocardial ischemia due to an
imbalance between myocardial
oxygen supply and demand.4
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Transient Myocardial Transient Myocardial ischemiaischemia
Severe Chest painSevere Chest pain
Myocardial Blood Flow
Myocardial O2 Demands
Fixed threshold angina
Variable threshold angina
Clinical Manifestations
Differential Diagnosis of Chest Pain
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• FIXED-THRESHOLD= Angina Caused by Increased Myocardial O2 Requirements
• VARIABLE-THRESHOLD = Angina Caused by Transiently Decreased O2 Supply
• MIXED ANGINA.
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Differential Diagnosis of Chest Pain
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Physical Examination
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Pathophysiology
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Noninvasive Testing • Biochemical Tests :Aop-ProB, LPa, LDL(smal dense), LP-PL A, homocysteinInflammation: hsCRP, BNP, Soluble CD4, Risk factors: FBS, HBA1c &…
• Resting Electrocardiogram
• Noninvasive Stress Testing
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Resting Electrocardiogram
50% durig pain = NL-ECG
50% between attacks 50% between attacks :: ECG is entirelyECG is entirely NORMALNORMAL
Other : old problemsOther : old problems
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Exercise ECG showing typical severe down sloping Exercise ECG showing typical severe down sloping ST ST segmentsegment : :
Anginal pain is often associated with Depression Anginal pain is often associated with Depression of of STST segment segment
Standing 1 min. 3 min. 7 min. 9 min.
Noninvasive Stress Testing
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• Computed Tomography (MSCT):90%=sensitivity 50% = specificity
• Cardiac Magnetic Resonance Imaging
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Catheterization, Angiography, and Coronary Arteriography
• SVD = 2VD = 3VD = 25%.• LML = 5 – 10%.• NL-CAG = 15%.
diffuse disease than MI
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Natural History of Angina Pectoris and Risk Stratification
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Management of Stable Angina(1) identification and treatment of associated diseases that can
precipitate or worsen angina;
(2) reduction of coronary risk factors;
(3) application of general and nonpharmacological methods, with particular attention to adjustments in life style;
(4) pharmacological management;
(5) revascularization by percutaneous catheter-based techniques or by coronary bypass surgery
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Stop smokingStop smoking Reduce weightReduce weight
Treat Hypertension , Treat Hypertension , Hypercholestrolimia Hypercholestrolimia
and Diabetes and Diabetes
AVOID AVOID Severe Severe exertionexertion
Heavy mealHeavy meal EmotionsEmotions Cold WeatherCold Weather
General measures
20•Graduated exercise may open new collaterals
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Treatment of an acute attack of anginaSublingualSublingual nitroglycerin nitroglycerin (0.5 mg ) or isosorbide (0.5 mg ) or isosorbide
dinitrate (5 mg ) dinitrate (5 mg ) or Oral sprayOral spray nitroglycerinnitroglycerin (0.4 mg/metered (0.4 mg/metered
dose), dose), isosorbide dinitrateisosorbide dinitrate(1.25 mg/metered (1.25 mg/metered dose) dose)
Relief within 1-3 min. Persistence of pain
Repeat nitroglycerin at 5 min. Repeat nitroglycerin at 5 min. interval (3 tab. max.)interval (3 tab. max.)
Relief not relieved
InfarctionHOSPITALIZATION
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What are the antianginal drugs?
Organic nitrates.
Calcium channel blockers.
- adrenoceptor blockers.
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-blocker + Long
acting Nitrate
-blocker +
Nifedipine/amilodipin
Verapamil or Diltiazem +
Nitrate
-blocker + Nitrate +
Nifedipine/amilodipin
????
??
??
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Anti-platelet
• ASPIRIN
• CLOPIDOGREL
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Rx for Risk factors
• HTN
• DM
• HLP - statins
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• ACE-Inh:
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Management of Variant Angina
Nitrates andNitrates and/or /or Ca-Ca- Channel Channel blockersblockersFor the acute attack & prophylaxisFor the acute attack & prophylaxis
Beta-Blocker?Beta-Blocker?
ASA?ASA?
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For patients not responding to adequate medical For patients not responding to adequate medical therapy:therapy:
•Percutaneous Transluminal coronary Percutaneous Transluminal coronary Angioplasty (PTCA)Angioplasty (PTCA)
•Coronary artery bypass grafting (CABG)Coronary artery bypass grafting (CABG)
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