CORONARY HEART DISEASE:

ANGINA PECTORIS

Anton V. Rodionov
Assistant Professor
Department of Internal Medicine #1

Classification
Coronary
Heart
Disease

Angina
Pectoris

Stable

Unstable

Acute
Myocardial
Infarction

Q - MI

Old
Myocardial
Infarction

Non Q - MI

Sudden
Cardiac
Death

DEFINITIONS (1)
Angina Pectoris - reversible ischaemia to
the myocardium, induced by increased work
load (causing characteristic chest pain) and
relieved by rest. The reversible ischaemia is
usually due to coronary artery disease.
During ischemia an imbalance occurs
between myocardial oxygen supply and
demand.

DEFINITIONS (2)
Unstable angina syndrome in which the patients risk
is intermediate between chronic stable angina and
myocardial infarction.
A clinical diagnosis based on a history of chest pain:
new onset (within 1 month)
crescendo angina (accelerating symptoms of previous
stable angina: more severe, prolonged, or frequent)
angina pectoris at rest as well as with minimal
exertion
Exclusion of myocardial infarction by cardiac markers
level

Epidemiology I
Death Rates for Total CVD, CHD, Stroke and Total
Deaths in Selected Countries (Revised 2005)

Epidemiology II
Deaths From Cardiovascular Diseases
United States:2003*

Source: CDC/NCHS and NHLBI. *Preliminary

Etiology
Atherosclerosis of the coronary artery is by far the
leading cause of CHD.
Non-Atherosclerotic Coronary Artery Disease
Congenital (anomalous origin of L or R coronary
arteries)
Arteritis associated with auto-immune diseases
(SLE, Kawasakis)
Coronary Ectasia
Radiotherapy
Syndrome X
Prinzmetals Angina - spasm

Risk factors I
Traditional risk factors for coronary heart disease

Lifestyles

Diet high in saturated fat,

cholesterol and calories
Tobacco smoking
Excess (!) alcohol
consumption
Physical inactivity

Biochemical or physiological
characteristics (modifiable)

Personal characteristics (nonmodifiable)

Elevated blood pressure

Elevated plasma total
cholesterol (LDL cholesterol)
Low plasma HDL cholesterol
Elevated plasma triglycerides
Hyperglycaemia/diabetes
Obesity
Thrombogenic factors

Age
Sex
Personal history of CHD or
other atherosclerotic vascular
disease
Family history of CHD at
early age (in men <55 years,
in women <65 years)

Atherosclerosis
Fibrous Plaque:
an advanced, complex,
occlusive lesion
characterized by a fibrous
cap of dense connective
tissue overlying a
collection of foamy
macrophages, necrotic
debris, T lymphocytes,
and smooth muscle cells.

Anatomy of the Atherosclerotic Plaque

Lumen

Lipid
Core

Fibrous
cap
Shoulder

Intima
Media

Source: www.lipidsonline.com

Elastic
lamin

Internal
External

Pathophysiology of angina

Rest

O2 Supply =
O2 Demand

Stress

O2 Supply <
O2 Demand

Regulation of Coronary Blood Flow

Coronary Anatomy
Vessel diameter (larger vessel - easier
flow)
Vessel resistance
Directly related to length of lesion
Collateral circulation
Provides alternate routes for blood flow

What determines O2 supply?

How does vessel

resistance affect
blood flow?
(Coronary
Anatomy)

Normal vs. Ischemic Heart Disease

Normal

Atherosclerotic

Normal Exercise

Atherosclerotic Exercise

Regulation of Coronary Blood Flow

Metabolic Regulation (adenosine)
Sympathetic Nervous System
1 mediated vasoconstriction
2 mediated vasodilatation
Parasympathetic Nervous System
Stimulation provides modest increase in coronary blood flow
Vascular Endothelial Tone
Endothelial Derived Relaxing Factor (EDRF)
Characterized as nitric oxide
Causes smooth muscle relaxation
Coronary Reflexes
Undetermined role

CLASSIFICATION OF STABLE ANGINA

Class I - strenuous or protracted exercise

Class II - slight limitation with vigorous
physical activity such as walking up a hill
Class III - marked limitation, with symptoms
during the activities of everyday living
Class IV - inability to perform the activities of
daily living & angina at rest
Canadian Cardiovascular Society 1975

Clinical Features
Chest Pain
Character (not pain but unpleasant sensation:
pressing, squeezing, strangling, constricting,
bursting, burning)
Site (typically retrosternal)
Radiation (typically left side: shoulder, arm, neck,
jaw, ear, scapula)
Inducing Factors
Relieving Factors
Duration
Dyspnea

Physical Signs
Usually none
Features of left ventricular failure

Diagnosis
The diagnosis of CHD based on:
Clinical history of angina
History of previous miocardial infarction
Evidence of atherosclerotic lesions in coronary
arteries
Demonstration of stress-induced ischemia or
reduced myocardial perfusion
Demonstration of impaired myocardial metabolism
The last three positions could be revealed by
different diagnostic methods, which include
noninvasive or invasive modalities.

Lab Tests

Blood account (anemia)

Biochemical tests (cholesterol and its
fractions, cardiac markers)
Coagulation and platelets aggregation

Noninvasive tests

Resting Electrocardiogram
Exercise electrocardiography (exercise stress-test; including
transesophageal electrical atrial pacing)
Radionuclide studies
exercise single photon emission computed tomography (SPECT)
pharmacological stress SPECT (dobutamine, dipyridamole or
adenosine)
radionuclide ventriculography
Stress-echocardiography
pharmacological stress ECHO (dobutamine, dipyridamole or adenosine)
stress-echocardiography with transesophageal electrical atrial pacing
Positron-emission tomography
Multispiral CT - angiography (or Electron-beam tomography)
MR - angiography
Ambulatory (Holter) ECG monitoring

ISCHEMIC CASCADE

course & severity of ischemia

Angina/Symptoms
ECG changes

test
ECG

Systolic
dysfunction
Diastolic
dysfunction

ECHO

Metabolic changes

Radionuclide
Abnormal perfusion

Exercise stress-test

ECG - ischaemia

Thallium Scan

Echocardiography

Invasive tests

Coronary angiography (with left ventriculography)

Intravascular ultrasound

Indications for CAG in patients with

Stable Angina
Diagnostic
In patients with
indefinite diagnosis
(possible CHD)

Before
revascularization
In patients with
class III-IV angina
resistant to the
treatment
Recurrent angina
after MI, CABG,
PCI

Coronary Angiography

THERAPY

Risk Modification
Medical therapy
Balloon Angioplasty
Surgery
Cardiac Rehabilitation

Risk Modification

Stop smoking
Adequate treatment of hypertension
Good diabetic control
Lipids, treat LDL & TGs
Weight reduction
Regular exercise

Reduction of mortality

Aspirin (Clopidogrel if ASA is contraindicated)

Statins
-Blockers
ACE-inhibitors (Perindopril and Ramipril)
CABG in selected patients

Acetyl Salicylic Acid

ASA blocks COX and tromboxane A2
synthesis in platelets
Should be given to ALL patients with CHD
(except for those with absolute
contraindications)
Daily dose 75-100 mg
Decrease the total CV risk for 33%

Statins
Block 3-hydroxy-3-metylglutaril-coenzym reductase (HMG-coA reductase) and reduce
cholesterol synthesis at the liver
Should be given to patients with CHD if the
LDL cholesterol is higher than 130 mg/dl
The daily dose should be adequate to
maintain the LDL level < 1.8 mmol/l
Decrease the total CV risk for 20-40%

Beta blockers

Selective 1 and unselective

Antagonizes beta adrenergic effects
Reduces work load (HR & contractility)
Improves survival as well as treat symptoms
Side effects:
lethargy & tiredness, cold peripheries
unselective -blockers (UBAB) cause
brochospasm (avoid UBAB in asthma & COPD)
Caution in heart failure*
Carvedilol, Metoprolol, Bisoprolol and Nebivolol
improves survival in pts. with heart failure

Mechanism of Action of Beta Blockers

ACE-inhibitors
Main mechanism of action inhibition of
angiotensin converting enzyme
Prevent and reduce the myocardium
remodeling
Should be given to those patients with CHD
having previous MI, any systolic dysfunction,
diabetes mellitus or arterial hypertension

Calcium Antagonists
Smooth muscle relaxant, reduces pre & after
load.
Direct cardiac depressant as well
3 classes
Dihydropyridine nifedipine, amlodipine,
felodipine
Benzithiazepines Diltiazem
Phenylalkylamines Verapamil

Nitrates

Smooth muscle relaxant

Pre-load, after-load reduction
Dilate coronary arteries
Side effects - hypotension, flushing,
headaches, increased heart rate

No favorable effects on mortality

Unstable Angina
Aspirin (& clopidogrel)
Low Molecular Weight Heparin (or
unfractioned if LMW isnt available)
Beta blockers
Oxygen
Nitrate infusion
Monitor ECG & BP
?? Glycoprotein IIb/IIIa antagonists
?? Calcium antagonists

Transluminal coronary balloon

angioplasty and stenting

Coronary artery bypass grafting