cpm1st chronic stable angina.pdf

8/14/2019 CPM1ST CHRONIC STABLE ANGINA.pdf

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C HRONIC S TABLE A NGINA

ST. LUKES MEDICAL CENTER- THE HEART INSTITUTE


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CHRONIC STABLE ANGINA

Gregorio G. Rogelio, M.D.Osler Galen F. Cario, M.D.


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409

CPM 1 ST EDITION

Algorithm for the Management of Patients with Chronic Stable Angina

1

Chronicstable angina

(A)

FIGURE 1

2

stratifyrisk (B)

high risk?

6

medicalmanagement

(C)

3

N

amenableto invasive

procedures?

4

surgicalcandidate

5

Figure IAYY

N


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CHRONIC STABLE ANGINA CPM 1 ST EDITION

410

Algorithm for the Management of Chronic Stable Angina in PatientsAmenable to Invasive Procedures

1

surgicalcandidate

2

coronaryangiography

Figure I

3

suitable forPTCA?*

4

PTCA*

5

suitablefor

CABG?**

6

CABG**

6

medicalmanagement

FIGURE 1A

* PTCA - percutaneous transluminal coronary angioplasty ** CABG - coronary artery by pass graft


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411

CPM 1 ST EDITION

Footnotes

A. Stable angina is de ned as having the followingclinical features: predictable pattern of chest dis-comfort, begins gradually lasting over a period of10-15 minutes, precipitated by effort & relieved byrest or nitrates [1].

B. Risk strati cation should be based on the follow-ing parameters: clinical ndings, LV function &low level treadmill exercise test, stress thallium,dipyridamole stress test, or dobutamine stressechocardiogram [2]. These clinical predictors ofimportant prognostic signi cance include:

1. poor exercise capacity (2 min ischemic ST segment depression at low

workload (< stage 2 or 5min) of ST segment depression

4. multiple leads (>5) with ST segment depression 5. ST segment elevation 6. abnormally low peak systolic BP (10 mmHg systolic BP during exer-cise

7. inability to attain the target heart rate (withoutmedications)

8. exercise-induced angina 9. ventricular couplets or ventricular tachycardiaat a low workload

10. multiple severe initial thallium defects11. multiple areas showing thallium redistribution [3]

12. increased lung/heart thallium ratio [4] 13. transient ischemic left ventricular dilation on

stress thallium [5] 14. left ventricular dysfunction on echo [6]

C. Medical Treatment

1. Nitrates decrease myocardial oxygen demand byreducing both preload & afterload, & enhancemyocardial blood ow by prevention of coro-nary vasoconstriction, reduction of LVEDP &dilation of coronary arteries [7].

2. Beta-blockers decrease heart rate & systolicBP, increase diastolic rilling period & coronary

perfusion time, decrease myocardial oxygendemand. Beta-blockers alone or in combina-tion with Ca antagonists are associated withMI prevention & reduction of anginal attacks,& increased anginal threshold [8].

3. Ca channel blockers reduce afterload & causecoronary vasodilation & prevent coronaryspasm [9].

4. Aspirin (platelet inhibitors) 75-325 mg reducescardiac events by 34-87% [10-11].

Medical management includes control of modi ablerisk factors such as smoking, hypertension, diabetes &hypercholesterolemia, & aggravating factors such asfever, anemia, thyrotoxicosis, infection, etc.

D. Coronary Angiography [12-15]

1. With signi cant (60%) left main coronary arterydisease & for most with signi cant (70%) 3-ves-sel coronary artery disease, CABG is advised.

2. With signi cant 2 vessel disease & 1-vesseldisease, the option of CABG, PTCA or medicaltreatment will be considered.

3. With critical obstruction of the proximal leftanterior descending artery with significantobstruction of one other major vessel & moder-ate angina &/or inducible ischemia, CABG orPTCA is advised.

4. With signi cant single-vessel disease, the deci-sion for CABG, PTCA or medical treatment ismade individually. PTCA or CABG is favoredfor those with non-invasive testing which indi-cates exercise-inducible ischemia (70%).

References

1. Lambert CR. Fathophysiology of stable angina pectoris. In

Crawford M (ed): Cardiology Clinics. Philadelphia, W.B.Saunders Company 1991;9:1-10,

2. Hammermeister KE, Deronen TA, Dodge HY. Variables predictive of survival in patients with coronary disease.Circulation 1977;59:421.

3. Brown KA, Boucher CA, Okada RD, et al. Prognosticvalue of exercise thallium 201 imaging in patients

presenting for evaluation of chest pain. J Am Coll Cardiol1984;1;1994.

4. Kaul S, Finkelstein DM, Homma S et al. Superiority ofquantitative exercise thallium 201 variables in determininglong-term prognosis in ambulatory patients with chest

pain; a comparison with cardiac catheterization. J Am Coll

Cardiol 1988;12:25. 5. Weiss AT, Berman DS, Lew AS et al. Transient ischemic

dilation of the left ventricle on stress thallium 201scintigraphy: a marker of severe & extensive coronaryartery disease. J Am Coll Cardiol 1987;9:752.

6. Mock MB, Ringquist I, Fisher LD. Survival of medicallytreated patients in the coronary artery surgery studyregistry. Circulation 1982;66:562-68.

7. Udho T. Medical therapy of stable angina pectoris. InCrawford M (ed):Cardiology Clinics. Philadelphia, W.B.Saunders Company 1991;9-73-87.

8. Rutherford MB, Braunwald E. Chronic ischemic heartdisease. In Braunwald E (ed): Heart disease: A textbook

of cardiovascular medicine 14th ed. Philadelphia, W.B.Saunders Company 1991;1292-1364,

9. Packer M. Drug therapy: combined beta adrenergic &calcium entry blockade in angina pectoris. N Engi J Med1989;320;709.

10. Eduardson N, Jahnmatz B et al. Double blind trial of Aspirinin primary prevention of myocardial infarction in patientswith stable angina pectoris. Lancet 1992;340:1421-25.

11. Ridker PM, Manson JEE, Gaziano M, et al. Low dose


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CHRONIC STABLE ANGINA CPM 1 ST EDITION

414

Aspirin Aspilets ................................ 155 Astrix ................................... 155 Bayer Aspirin ...................... 155 COR-30 ............................... 156

Beta blockers Atenolol Serten ................................... 129 Tenormin ............................. 130 UL Atenolol ......................... 130

Betaxolol

Kerlone ................................ 130 Bisoprolol Concore ............................... 130Carteolol Mikelan ............................... 130

Metoprolol Betaloc ................................. 130 Betazok ................................ 131 Cardiosel ............................. 131 USA Metoprolol .................. 131

Nadolol Corgard ................................ 131

Pindolol Visken .................................. 131

Propranolol Bedranol .............................. 131 Duranol ................................ 131 Inderal ................................. 132 Propranolol- Phoenix ............................. 132 Propranolol- Scanpharm ........................ 132 UL Propranolol .................... 132

Sotalol Sotalex ................................. 132

Atenolol/Chlorthalidone Tenoretic .............................. 132

Metoprolol/Hydrochlorothiazide Betazide ............................... 132

Pindolol/Clopamide Viskaldix ............................. 132

Calcium Channel Blockers Amlodipine Norvasc ............................... 132

Diltiazem Dilatam ................................ 134 Diltelan ................................ 134 Dilzem/Dilzem SA/SR ........ 134

Drugs Mentioned in the Treatment GuidelineThe following index lists therapeutic classi cations as recommended by the treatment guideline. For the prescriber'sreference, available drugs are listed under each therapeutic class.

Nitroglycerin Deponit 5/Deponit 10 .......... 146 Minitran TDP ...................... 146 Nitradisc .............................. 146 Nitrol ................................... 147 Nitrostat ............................... 147 Perlinganit ........................... 147 Transderm-Nitro .................. 147

Pentaerythritol tetranitrate Peritrate .............................. 148

Servazen .............................. 134 Tildiem ................................ 134 Zilden .................................. 134Felodipine Munobal .............................. 134 Plendil ER ........................... 134

Isradipine Dynacirc .............................. 134 Icaz SRO ............................. 136

Lacidipine Lacipil ................................. 136

Manidipine

Caldine ................................ 136 Minadil ................................ 136 Nicardipine Cardepine ............................ 136 Selevax ................................ 136

Nifedipine Adalat .................................. 136 Calcibloc ............................. 136 Cardionorm ......................... 138 Darat .................................... 138 Fedcor .................................. 138 Nifelan ................................. 138

Nimodipine Nimotop ............................... 138

Nitrendipine Baypress .............................. 138Verapamil Hinorm ................................ 138 Isoptin/Isoptin SR ................ 138 Verelan ................................. 139

Atenolol/Nifedipine Niften ................................... 139

Organic Nitrates & Nitrites Isosorbide Cedocard ............................. 144 Elantan ................................. 144 Elantan Long ....................... 144 Imdur Durules ..................... 144 Ismo 20 ................................ 144 Isoket ................................... 144 Isoket IV .............................. 144

Isoket Spray ......................... 144 Iso-Mack Retard .................. 144 Iso-Mack Spray ................... 146 Isordil .................................. 146 Isordil Tembids .................... 146 Monovas .............................. 146 Nitorol ................................. 146

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