Stable Angina Pectoris

.Yazeed algahim,pharmD

Definitions, Characteristics &

Ischemia is a decrease in blood supply to a tissue
Angina pectoris- a coronary ischemic event
characterized by paroxysmal feeling of
pain/discomfort/heaviness in the chest, jaw,
shoulder, back, or arm
In stable angina (SA)
the pain occurs on exertion & follows the same
pattern, is of the same intensity & severity
The pain lasts for < 20 min., and is relieved by rest
or nitroglycerin (NTG)
In unstable angina (UA)
The pain occurs even at rest & changing in pattern
The pain is of increased intensity & severity, and
not relived by rest or NTG
Both of these two angina types are mainly due to
atherosclerotic narrowing of the coronary arteries
Vasospastic angina is another type of angina,
and is due to vasoconstriction of coronary arteries

(MI)- death of part of

the
heart muscle
Classifications
UA & MI are classified
under what is called
Acute Coronary
Syndrome, ACS
ACS is subdivided
into
ST-segment
elevation ACS
(STE ACS)- also
called STE
myocardial
infarction (STEMI)
Non-ST-segment
elevation ACS
(NSTE ACS)
includes NSTEMI
& UA

Causes & Risk Factors- The

Atherogenics

Hyperlipidemia
Smoking
Diabetes mellitus
Hypertension
Sedentary life style
Obesity (abdominal
obesity)
Stress
Family Hx
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These risk factors

are additive

Precipitating Factors

Mild, moderate, or
heavy
exercise, depending
on patient
Effort that involves use
of arms above the head
Cold environment
Walking against the
wind
Walking after a large
meal
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Emotions
Fright
anger
anxiety

Coitus

Pathophysiology
Coronary
atherosclerosis/vasospa
sm reduces myocardial
perfusion
Increase in the
myocardial oxygen
demands in relation to
supply
This leads to anaerobic
respiration, resulting in
lactic acid production &
pain
sensation
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Diagnosis
ECG
SA
ST-segment depression (> 2
mm) & T-wave inversion upon
exercise tolerance test
(exercise treadmill test)
vasospastic angina
ST-segment elevation upon
ergonovine stimulation test

Myocardial
imaging (echo &
nuclear)
Coronary
catheterization (w
angiography & ?
angioplasty)

Normal ECG

Normal

Treatment- Goals

Relieving the pain

Preventing/decreasing future attacks
Preventing complications
Improving patients quality of life
Increasing tolerance to daily life
activities
Preventing adverse drug reactions as
much as possible

Treatment- Stable Angina

Treatment- Stable Angina

10

The treatment algorithm for

ischemic heart disease. It
begins at the top (black
section), which suggests risk
factor modifications as the
first treatment modality.
Moving down to the dark gray
section, appropriate
antiplatelet therapy is
selected. The light gray
section identifies patients at
high-risk for major adverse
cardiac events and suggests
appropriate drug therapy to
decrease cardiovascular risk.
The white section at the
bottom recommends
appropriate anti-anginal
therapy. ACE-I, angiotensinconverting enzyme inhibitor;
ARB, angiotensin receptor
blocker; BMS, bare metal
stent; BP, blood pressure;
CABG, coronary artery bypass
graft; CCB, calcium channel
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blocker; DES, drug-eluting

Treatment- Primary
Prevention
Aims at preventing
IHD/ACS by
modification of
modifiable risk factors
Treating aggravating
medical conditions

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Diabetes mellitus
Hyperlipidemia
Hypertension
Thyrotoxicosis
Tachycardia
Anemia
fever
Hypoxemia

Life style
modification
Smoking cessation
Regular aerobic
exercise
Weight reduction
stress reduction

Treatment- Drugs- Stable

Angina
NTG
SL tab/lingual spray
for acute attack & for prophylaxis
before precipitating activities
mg, repeated if symptoms 0.3-0.6
persist after 3-5 min., but not > 3
doses
Take while sitting
Store tab properly

An Antiplatelet
Aspirin 81 mg daily
Clopedogrel

B-blockers, BB (cardioselective)
Atenolol/Metoprolol
to decrease the number, severity,
and duration of angina
HR (resting) not to be <55-60
beat/min
Can cause AV block,
bronchoconstriction, decreased
exercise
tolerance, PVD, impotence
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Diltiazem (a CCB)
As add-on or alternative esp. if BP is
elevated
DOC in vasospastic angina
Verapamil , felodipine or amlodipine can be
used
Avoid diltiazem & verapamil in CHF
Long-acting nitrates (LAN)
Isosorbide mononitrate/dinitrate or NTG
transdermal patch
As an add-on if the BB/CCB not adequate or
As alternative if the BB/CCB cannot be
tolerated
Can cause headache & flushing
Tolerance can develop
Minimized by drug-free interval (10-12 hrs
daily)
CCB or BB should be there during the
nitrate-free interval
Ivabradine & ranolazine (New treatment
modalities)
Any to be used in combination w
conventional drugs
Ivabradine is alternate to BB for HR control
(via SA node)
Ranolazine has no effects on BP or HR
(nothing to do w supply/demand)
prolongs QT interval, has a lot of DDI
(ketoconazole, Diltiazem & Verapamil should

Desired Outcomes & Outcome

Evaluation- SA
Reduced frequency, severity &
duration of anginal episodes & NTG
consumption
Improvement in exercise tolerance

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Coronary Bypass Surgery

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