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Yang HaiBo MD
Department of cardiology,
1st affiliated hospital of ZZU
types of CAD
asymptomatic ischemia
angina pectoris
myocardial infarction
ischemic cardiomyopathy
sudden cardiac death
Stable angina pectoris
Angina Pectoris
(AP)
Unstable angina pectoris
(UAP)
◆ alleviating factors
First Description of Angina
Those who are afflicted with it are seized while they are
walking (more especially if it be uphill, and soon after
eating), with a painful and most disagreeable
sensation in the breast, which seems as if it would
extinguish life, if it were to increase or to continue; but
the moment they stand still, all this uneasiness
vanishes.This elegant description by William Heberden
first published 225 years ago eloquently captures the
symptomatic characteristics of angina pectoris. It is a
common and important symptom affecting many patients
with coronary artery disease.
Heberden W. Classics of Cardiology. Dover Publications, 1941; I:221.
Angina is unpleasant sensation,
usually not pain
The unpleasant sensation is more typically
characterized as a pressure or tightness,
a heaviness 、 squeezing or burning
Most patients with true angina do not use
this term to describe their sensation.
The pressure is not perceived by the patient
as pain such that the interviewer who
specifically asks about pain may be misled
CHARACTERISTICS OF TYPICAL AND
ATYPICAL ANGINA PECTORIS
Typical
• Substernal ,Characterized by a heavy, squeezing or burning
feeling
• Precipitated by exertion or emotion
• Promptly relieved by rest or nitroglycerin
Atypical
• Located in the left chest, abdomen, back, or arm in the absence
of mid-chest pain
• Sharp or fleeting
• Repeated, very prolonged
• Unrelated to exercise
• Not relieved by rest or nitroglycerin
• Relieved by antacids
• Characterized by palpitations without chest pain.
The usual distribution is referral to all or part of the sternal
region, the left side of the chest, and the neck and down the ulnar
side of the left forearm and hand. With severe ischemic pain, the
right chest and right arm are often involved as well, although
isolated involvement of these areas is rare. Other sites sometimes
involved, either alone or together with other sites, are the jaw,
epigastrium, and back.
Provoking &Exacerbating
Factors
Classic Precipitation: exercise &
emotional stress
Other Precipitants: high pressure meeting
stressful emotional incident
cold weather activity
heavy meals
lying down (at times )←venous return↑
Alleviating Factors
*Cessation of activity
*Sublingual nitroglycerin--nonspecific
*Getting out of the cold
*Completing the uphill walk
In Summary :cessation
that increase cardiacofoxygen
a factor
demand
Signs during Angina
*Softening of the S1- result of ischemic left ventricular
dysfunction
Usually normal
……
Diagnostic Tests:ECG
Rest ECG
Captured during an episode
Exercise ECG
Ambulatory Holter monitoring
Diagnostic Tests: Rest ECG
ECG at rest may commonly be normal in pts with AP.
In the Rochester, Minnesota, area, 59% of the 1154 individuals presenting with
chest pain were found to have normal resting ECGs (Mayo Clin Proc 1984; 59:247)
specific
STSegment
Depression
ST
Horizontal
Diagnostic Tests:Echocardiography
Left ventricular (LV) evaluation is
probably the single most important
*overall systolic function
*regional wall motion
*ventricular mass
*geometry
Diagnostic Tests:Exercise ECT
Nuclear imaging techniques
transverse
sagittal
coronal
arachidonic acid
cyclo-oxygenase← inhibition (aspirin)
thromboxane A2(TXA2)
(the key modulator of irreversible platelet aggregation)
Medical Therapy:Nitrates
Reduce preload
Reduce afterload
Dilate epicardial coronary
Nitric oxide (NO)
* Adapted from Abrams J. Therapy of angina pectoris with long acting nitrates: Which agent and when. Can J Cardiol 1996; 12C:9C-16C.
GTN indicates nitroglycerin; ISDN, isosorbide Dinitrate; IS-5-MN, isosorbide-5-mononitrate; and SR, sustained release.
* A nitrate-free interval of at least 8 h per 24-h period should be provided to avoid tolerance.
Medical Therapy :Nitrates
Principle side effects
headache flushing lightheadness
Occasionally side effects
nitrates syncope
Because: a rapid decline in systolic blood pressure in the
upright position, associated with arterial dilatation and venous
pooling.
Medical Therapy :ß-blocker
Mechanism
ß-blocker
Medical Therapy: Pharmacology
classes of ß-receptors :ß -1 and ß -2
Cardioslectivity:
nonselective: affect the heart, peripheral vasculature, bronchial
tree, and modulation of hepatic and skeletal muscle
glyconeogenesis
ß -1 selective: (metoprolol and atenolol) tends to circumvent the
undesirable consequences (constriction of the bronchial tree and
arterial smooth muscle ) of nonselective b-blockade
Selective b-1 blocker effects, however, are only relatively selective,
and at increased doses these agents produce ß -2 blockade
Medical Therapy :ß-blocker
Name (proprietary) Property Frequency Daily dose, mg
Propranolol (Inderal) Nonselective Twice a day 80-320
(Inderal LA) Daily 60-320
Nadolol (Corgard) Nonselective Daily 80-240
Timolol (Blocadren) Nonselective Twice a day 15-45
Metoprolol (Lopresor) B1 selective Twice a day 100-400
(Lopresor SR) Daily 100-400
Atenolol (Tenormin) B1 selective Daily 50-200
Acebutolol (Sectral) B1 selective partial ISA Twice a day 200-600
Pindolol (Visken) Nonselective ISA Twice a day 15-45
Three times a day (>30 mg total)
Sotalol (Sotacor)* Nonselective with type 3 Twice a day 160-480
antiarrhythmic effect
* Sotalol is not approved for angina pectoris use. ISA indicates intrinsic sympathomimetic activity.
Medical Therapy :ß-blocker
Untoward effects of nonselective ß-blockade
Coronary vasoconstriction : Prinzmetal variant angina×
Peripheral circulatory vasoconstriction : Raynaud’s disease×
Bronchial constriction: Asthma, COPD ×
↓Response to hypoglycemia
Impaired hepatic gluconeogenesis
Impaired general awareness
↓Triglycerides/↓high-density lipoprotein cholesterol
Medical Therapy :Calcium-blocker
When symptoms persist or side effects limit
treatment with ß-blockers and/or nitrates, the
use of calcium antagonists may provide
significant additional relief.
It has been suggested that a special niche for
calcium antagonists resides with Prinzmetal’s
variant angina patients .
Medical Therapy :Calcium-blocker
Classification of calcium-blocker
*Dihydropyridines
nifedipine
SR nifedipine
longer-acting: felodipine amlodipine
*Diltilzem
*Verapamil
Medical Therapy: Calcium-blocker
provoking factors alleviating factors
↑ demand demand ↓
Medical Therapy :Calcium-blocker
Calcium channel blockers: dosing and properties
@dietary modification
@ideal body weight (obesity)
@reduces cholesterol and saturated fat
@cessation of smoking
@controlling elevated blood pressure and blood sugar
@regular physical activity into a patient’s daily
@HMG-Co A (hydroxy-methylglutaryl co-enzyme A ) reductase
big five risk factors
atherosclerosis
hypertension
smoking
diabetes
hypercholesterolemia
and family history
Risk Assessment & Reduction
HMG-Co A reductase inhibitor
HMG-Co A (hydroxy-methylglutaryl co-enzyme A )reductase
HMG-Co A reductase inhibitor (statin)
CH ↓25%
LDL↓35%
STENT
stent_webvsn.avi
Coronary artery
bypass graft
(CABG)
Approach to Patients with Chronic Stable Angina