Chronic Stable Angina

Definition Chronic stable angina pectoris is an episodic clinical manifestation of ischemic heart disease (IHD) due to transient myocardial ischemia. Etiology and risk factors are already discussed Symptoms & Signs Stable angina is characterised by central/ retrosternal chest pain, discomfort or breathlessness that is precipitated by exertion and is promptly relie ed by rest. !eatures of chest discomfort "ypically last for #$% minutes Character& hea iness, s'uee(ing, cho)ing "ypically radiates to the left shoulder and to both arms, especially to the ulnar surfaces of the forearm and hand *typical chest discomfort more common in elderly persons (+,% years), -omen, and diabetic patients atypical chest pain can arise in or radiate to the bac), interscapular region, root of the nec), .a-, teeth, and epigastrium Precipitating factors for angina pectoris Hea y physical exertion, climbing stairs/uphill Sudden exposure to cold *fter hea y food (post prandial angina) /motional stress angina is typically relie ed by slo-ing or ceasing acti ities in 0$% min and e en more rapidly by rest and sublingual nitroglycerin 1ay also occur at rest (unstable angina) and at night -hile the patient is recumbent (angina decubitus) "hreshold for angina pectoris may ary by time of day and emotional state. Some patients ha e fixed threshold for pain. *nginal 2e'ui alents2 are symptoms of myocardial ischemia other than angina. "hey are dyspnea, fatigue, and faintness .1ore common in elderly persons, diabetic patients, and -omen Silent ischemia & 3ithout chest discomfort but detectable by continuous electrocardiography (/C4) (Holter monitoring) or during stress testing Sometimes the pain may occur at the beginning of a -al) and disappear on further -al)ing. "his is )no-n as 2-al)&through phenomenon2 or 23enc)ebach5s second&-ind phenomenon2. 3hen the patient is as)ed to locali(e the sensation, he or she -ill typically place their hand o er the sternum, sometimes -ith a clenched fist, to indicate a s'uee(ing, central, substernal discomfort (6e ine7s sign) Physical examination 1ost often normal

 1ay re eal atherosclerotic disease at other sites& *bdominal aortic aneurysm Carotid arterial bruits, Diminished arterial pulse in the lo-er extremities Hypertension may be present Chec) for signs of anemia, thyroid disease, and nicotine stains on the fingertips from cigarette smo)ing. 8anthoma could gi e clue for underlying dyslipidemia. C9S examination :alpation may re eal cardiac enlargement and abnormal contraction of the cardiac impulse (left entricular ;69< a)inesia or dys)inesia). "enderness of chest -all or reproduction of the chest discomfort -ith palpation ma)es angina unli)ely. *uscultation & third and/or fourth heart sound, 1= murmur(due acute ischemia or pre ious infarction has impaired papillary muscle function) During angina & Ischemia can cause transient 69 failure -ith the appearance of a third and/or fourth heart sound, a dys)inetic cardiac apex, mitral regurgitation, and e en pulmonary edema. Differential Diagnosis 1)Unstable angina Duration> 0?$#? minutes @uality> similar to chronic stable angina, but often more se ere 6ocation> similar to chronic stable angina *ssociated features> similar to chronic stable angina, but occurs -ith lo- le els of exertion or at rest 2) Acute MI Duration> often longer than A? minutes @uality> similar to chronic stable angina, but often more se ere 6ocation> similar to chronic stable angina *ssociated features> unrelie ed by nitroglycerinB may be associated -ith e idence of heart failure or arrhythmia )Aortic stenosis Duration> recurrent episodes as described for angina @uality> as described for angina 6ocation> as described for angina Associate! features> late&pea)ing systolic murmur radiating to carotid arteries ")Esophageal reflux Duration> 0?$C? minutes @uality> burning 6ocation> substernal, epigastric *ssociated features> -orsened by postprandial recumbencyB relie ed by antacids #) $sophageal spasm

Duration> #$A? minutes @uality> pressure, tightness, burning 6ocation> retrosternal can closely mimic angina

%)$motional an! psychiatric con!itions Duration> ariableB may be fleeting @uality> ariable 6ocation> ariableB may be retrosternal *ssociated features> situational factors may precipitate symptomsB anxiety or depression often detectable -ith careful history &) Musculos'eletal pain $ history of trauma -ill be present. local tenderness may be present (e) *or' +eart Association functional classification of angina I :atients -ith cardiac disease but -ithout resulting limitations of physical acti ity. Drdinary physical acti ity does not cause undue fatigue, palpitation, dyspnoea or anginal pain. II :atients -ith cardiac disease resulting in slight limitation on physical acti ity. "hey are comfortable at rest. Drdinary physical acti ity results in fatigue, palpitation, dyspnoea or anginal pain. III :atients -ith cardiac disease resulting in mar)ed limitation of physical acti ity. "hey are comfortable at rest. 6ess than ordinary physical acti ity causes fatigue, palpitation, dyspnoea or anginal pain. I9 :atients -ith cardiac disease resulting in inability to carry on any physical acti ity -ithout discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present e en at rest. If any physical acti ity is underta)en, discomfort is increased.

Diagnosis "he history is by far the most important factor in ma)ing the diagnosis. Diagnosis is confirmed by stress testing or coronary angiography ,aboratory -ests A) .outine in/estigation for i!entification of ris' factors 1easurements of lipids 6D6 cholesterol ,HD6 cholesterol ,"riglycerides 4lucose Creatinine Hematocrit Erine $ microabuminuria 0)Diagnostic in/estigations 1).esting $C1

Formal in about half of patients -ith typical angina pectoris may sho- old 1I or nonspecific "&-a e changes 2) $xercise stress $C1 2stress testing) *n exercise tolerance test (/"") is usually performed using a standard treadmill or bicycle ergometer protocol -hile monitoring the patient7s /C4, blood pressure and general condition 4oals "o detect typical /C4 signs of myocardial ischemia "o establish the relationship of these findings to chest discomfort "echni'ue "he test consists of a standardi(ed incremental increase in external -or)load on treadmill or bicycle -hile symptoms, /C4, and arm blood pressure are monitored. "arget heart rate is G%H of maximal heart rate for age and sex. "est is discontinued upon e idence of> Chest discomfort Se ere shortness of breath S"&segment depression + ?.# m9 (# mm) Decrease in systolic blood pressure + 0? mmHg De elopment of entricular tachyarrhythmia Interpretation Ischemic S"&segment response is generally defined as flat depression of the S" segment +?.0 m9 belo- baseline (i.e., the := segment) and lasting longer than ?.?G seconds !ailure of blood pressure to increase or an actual decrease -ith signs of ischemia during the test is an important ad erse prognostic signB it may reflect ischemia&induced global 69 dysfunction. D erall sensiti ity of exercise stress electrocardiography is only I,%HB a negati e result does not completely exclude C*D. the amount of exercise -hich can be tolerated and the extent and degree of any S" segment change can pro ide a useful guide to the li)ely extent of coronary disease. Contraindications to exercise stress testing =est angina -ithin JG hours Enstable rhythm Se ere aortic stenosis *cute myocarditis Encontrolled heart failure *cti e infecti e endocarditis 3ther forms of stress testing

 Stress myocardial perfusion imaging and stress echocardiography are more sensiti e and specific than exercise electrocardiography in the diagnosis of IHD but are more costly than stress /C4 Myocar!ial perfusion scanning "his may be helpful in the e aluation of patients -ith an e'ui ocal or uninterpretable exercise test and those -ho are unable to exercise.< "he techni'ue in ol es obtaining scintiscans of the myocardium at rest and during stress after the administration of an inra enous radioacti e isotope such as KK technetium tetrofosmin or thallium #?0 "hallium/ technetium are ta)en up by iable perfused myocardium * perfusion defect present during stress but not rest pro ides e idence of re ersible myocardial ischaemia -hereas a persistent perfusion defect seen during both phases of the study is usually indicati e of pre ious myocardial infarction Stress echocar!iography "he techni'ue uses transthoracic echocardiography to identify ischaemic segments of myocardium and areas of infarction "he characteristically exhibit re ersible defects in contractility during pharmacological stress -ith a dobutamine infusion Coronary arteriography Coronary arteriography pro ides detailed anatomical information about the extent and nature of coronary artery disease Diagnostic coronary angiography may be indicated -hen non&in asi e tests ha e failed to elucidate the cause of atypical chest pain. Management 1) $xplanation an! .eassurance "reatment should start -ith a careful explanation of the problem and a discussion of the potential lifestyle and medical inter entions that may relie e symptoms and impro e prognosis. A!/ice to patients )ith stable angina Do not smo)e *im at ideal body -eight "a)e regular exercise (exercise up to, but not beyond, the point of chest discomfort is beneficial and may promote collateral essels) * oid se ere unaccustomed exertion, and igorous exercise after a hea y meal or in ery cold -eather "a)e sublingual nitrate before underta)ing exertion that may induce angina 2)-reatment of .is' 4actors "reatment of dyslipidemiaB 6D6 cholesterol le el L #.C mmol/6 (0?? mg/d6) *ngiotensin&con erting en(yme inhibitor, especially in patients -ith hypertension, diabetes, and/or 69 dysfunction "reatment of hypertension

 Ideal -eight and super ised exercise program Strict control of sugars in diabetic patients ) Me!ical management a) Anti5anginal !rugs !our groups of drugs are used to help relie e or pre ent the symptoms of angina> nitrates, M&bloc)ers, calcium antagonists and potassium channel acti ators (itrates "hese drugs act directly on ascular smooth muscle to produce enous and arteriolar dilatationB their beneficial effects in angina are due to a reduction in myocardial oxygen demand (lo-er preload and afterload) and an increase in myocardial oxygen supply (coronary asodilatation). 9arious forms nitrates a ailable are& Sublingual /intra enous glyceryl trinitrate (4"F) and oral forms&isosorbide dinitrate and isosorbide mononitrate Side effects& headache, symptomatic hypotension and, rarely, syncope Continuous nitrate therapy causes pharmacological tolerance and this should be a oided by using a regimen that includes a nitrate&free period of C&G hours e ery day 0eta5bloc'ers "hese drugs lo-er myocardial oxygen demand by reducing heart rate, blood pressure and myocardial contractility Commonly used are metoprolol (%?&0?? mg bd) or atenolol (%? mg to 0?? mg daily). Side effects of all beta bloc)ers include depression, constipation, impotence, bronchospasm, heart failure, and bradycardia. M&bloc)ing drug should not be -ithdra-n abruptly because this may ha e a rebound effect and precipitate dangerous arrhythmias, -orsening angina or myocardial infarction (the M&bloc)er -ithdra-al syndrome). Calcium antagonists Calcium&channel bloc)ers are coronary asodilators that produce ariable and dose& dependent reductions in myocardial oxygen demand, arterial pressure and contractility Indicated in patients -ith> Inade'uate response to the combination of beta bloc)ers and nitrates *d erse reactions to beta bloc)ers (e.g., depression, sexual disturbances, fatigue) Common drugs are 9erapamil J? to G? mg tds, diltia(em A?&C? mg tds and nifedipine %&#? mg tds "he calcium antagonists may reduce myocardial contractility and can aggra ate or precipitate heart failure Dther side effects & peripheral oedema, flushing, headache and di((iness. Potassium channel acti/ators

 "his class of drug has arterial and enous dilating properties but does not exhibit the tolerance seen -ith nitrates. Ficorandil (0?&A? mg 0#&hourly orally) is the only drug in this class currently a ailable for clinical use. b) Antiplatelet agents 1)Aspirin "hromboxane *# reportedly causes platelet aggregation and is a potent asoconstrictor. *spirin, by acetylating cycloxygenase, inhibits thromboxane *# synthesis Dose &,%&0%? mg/day side effects &gastric ulcers and haemorrhage 2) Clopi!ogrel Dosage> ,% mg/d Can be used for aspirin intolerant patients Clopidogrel -ith aspirin can impro e coronary outcomes -hen gi en to patients for 0 year after an episode of unstable angina. In/asi/e treatment "he most -idely used in asi e options for the treatment of ischaemic heart disease include percutaneous coronary inter ention (:CIB including percutaneous transluminal coronary angioplasty, :"C*) and coronary artery bypass graft (C*N4) surgery. Percutaneous coronary inter/ention 2PCI) "his is performed by passing a fine guide-ire across a coronary stenosis under radiographic control and using it to position a balloon -hich is then inflated to dilate the stenosis. * coronary stent is a piece of coated metallic 7scaffolding7 that can be deployed on a balloon and used to maximi(e and maintain dilatation of a stenosed essel. drug&eluting stents are no- a ailable -hich reduce incidence of restenosis. Indications *ngina pectoris that limits lifestyle despite medical therapy single or t-o& essel disease pro ide palliati e therapy for patients -ith recurrent angina after C*N4 Contraindications *symptomatic or only mildly symptomatic patients Complications Dissection or thrombosis of the essel causing ischemia *d antages ersus C*N4 6ess in asi e Shorter hospital stay /asily repeated if necessary /ffecti e in relie ing symptoms

Disad antages ersus C*N4 =estenosis rate I#?H -ith bare metal stents High incidence of incomplete re asculari(ation En)no-n effect on outcomes in patients -ith se ere 69 dysfunction :oor outcome in diabetic patients -ith #& or A& essel coronary disease Coronary artery bypass grafting 2CA01) Indications *ngina refractory to medical therapy 1edical therapy not tolerated 6esions not amenable to :CI Se ere C*D (left main, A& essel disease -ith impaired 69 function) Diabetic patients -ith C*D in O # essels *d antages ersus :CI 1ore effecti e in relie ing symptoms Impro ed sur i al in certain subsets *bility to achie e complete re asculari(ation Disad antages ersus :CI 4reater cost Increased ris) of a repeat procedure due to late graft closure 1orbidity and mortality of ma.or surgery Complications :rogression to unstable angina MI CHF Cardiac arrhythmias Sudden death Syn!rome 6 "he constellation of typical angina on effort, ob.ecti e e idence of myocardial ischaemia on stress testing, and angiographically normal coronary arteries is sometimes )no-n as syndrome 8. "his disorder is poorly understood but carries a good prognosis and may respond to treatment -ith anti&anginal therapy.