Angina

Angina

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Angina1

What is anginaChest pain caused by transient myocardial ischemia due to an imbalance between Myocardial oxygen supply

Myocardial oxygen demand

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Classes

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Classes (cont.)Stable angina:

Most common type of angina

Common in smokers, hypertensive patients

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Classes (cont.)Unstable angina:Less common than stable angina

can occur at any time, duringstrenuous exerciseRest

Urgent condition and can progress to heart attack

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Classes (cont.)Prinzmetal Angina

vasospasm occursNarrowing of the coronariesNo buildup of fatty deposits in the artery walls

Experienced at night, which can be disruptive to sleep

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Pathophysiology7Coronaries narrow by plaque lead to stable angina

Clot formationlead to unstable angina

Video

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Causes 8

videoWhat Causes Angina -presentation.wmv

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Symptoms

The common symptoms:

Chest pain

Squeezing of the chest

Uncomfortable pressure

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Angina itself is a symptomHeavy pressure squeezing9

Symptoms (cont.)

Chest pain that may spread to :Left shouldersNeck ArmsJaws

The pain is milder when leaning forward

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Risk FactorsMajor non-modifiable

Age over 40

Gender ( > )

Family history

Major modifiable

Dyslipidaemia

Hypertension

Smoking

DM(insulin resistance)

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Risk Factors (cont.)Major non-modifiable

Age over 40

Gender ( > )

Family history

Major modifiable

Obesity

Sedentary lifestyle

Atherogenic diet

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Risk Factors (cont.)Minor Controllable

Lack of exercise

Personality

Extreme temperatures

Emotional Stress

Alcohol Abuse

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Risk Factors (cont.) 3 CAD risk factors (cholesterol, DM , smoking , HTN).

Prior CAD (cath stenosis 50%).

2 anginal events----- 24 hours.

ST segment deviation.

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DiagnosisECG ------ non-invasive (85% accurate).

Exercise stress test with ECG .

Holter monitoring (24 hrs ambulatory ECG).

Cardiac catheterization

Diagnostic

Therapeutic

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Diagnosis (cont.)ECGUseful to confirm angina pain and other abnormal features.

Must be coupled with some sort of stress test

ECG levels during a 24 hour period (used with nocturnal angina)

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Diagnosis (cont.)ECG17

Diagnosis (cont.)Angiography Insertion of a catheter to coronaries

Dye is injected

Detect blocks

Accurate

Effective

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Do not recommendations

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Exclude people from treatment based on their age.

Do not recommendations (cont.)

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Investigate/treat symptoms differently in men and women in different ethnic groups.

Do not recommendations (cont.)

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Offer vitamin or fish oil supplements

Do not recommendations (cont.)22

Offer TENS, EECP or acupuncture

TENS Transcutaneous electrical nerve stimulationEECP Enhanced External counter pulsation

Do not recommendations (cont.)23

Routinely offer drugs for 2ry prevention of CVD to people with suspected cardiac syndrome X

Cardiac syndrome Xis angina (chest pain) with signs associated with decreased blood flow to heart tissue but with normal coronary arteries

Management 24

Risk factor modification25

Limit alcohol

No high saturated fat/high cholesterol foods

Maintain normal blood lipid levels

Maintain blood pressure within normal range

Risk factor modification (cont.)Regular exercise

Optimal weight

Maintain blood glucose within normal range

No tobacco

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Pharmacological Management Pharmacological Management include:

Beta blockers

calcium channel blockers

Nitrates

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Pharmacological Management (cont.) Pharmacological Management include:

Antiplatelets

Other agents

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Beta blockers

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Beta blockers (cont.)

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Beta blockers (cont.) Pharmacological effects:

myocardial oxygen consumption by:

heart rate

blood pressure

myocardial contractility

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Calcium channel blockers 32

Calcium channel blockers (cont.)Pharmacological effects: Reduce trans membrane flux of calcium via calcium channels:

Negative chronotropicNegative inotropicSmooth Muscle relaxation

Therefore myocardial oxygen Consumption & Enhance coronary perfusion. 33

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Nitrates

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Nitrates (cont.)Pharmacological effects:Relax all types of smooth muscles vascular or non vascular.

Relax both arteries and veins but more effective on veins.

Increase cGMP that decrease platelet aggregation.

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Antiplatelets

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Antiplatelets (cont.)Pharmacological activity:

Prevent thrombus formation by inhibiting platelet aggregation by:

Inhibits prostaglandin synthesis by cyclooxygenase

Inhibitor of ADP-induced pathway for platelet aggregation

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Anti-ischemic agentsRanolazine

Inhibits fatty acid oxidation Inhibits late sodium current into myocardial cells

Prolongs QT interval

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Anti-ischemic agents (cont.)Ranolazine

Indicated for chronic angina unresponsive to other antianginal treatments.

Does not reduce blood pressure or heart rate

Therefore myocardial oxygen Consumption and maintain perfusion

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Surgery & Revascularization Surgical options includes:CABG

Veins fromSaphenous vein (leg)

Arteries fromInternal mammary artery (chest)

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Surgery & Revascularisation (cont.) Surgical options inlcludes:PCI

Use balloon

Use stent

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PCI Percutaneous coronary intervention

ComplicationsAngina condition can progress to myocardial infarction MI

MI includes permanant necrosis in the tissue of myocardium

Patient non responsive to NTG

Dont give more than 3 NTG sublingual pills

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Complications (cont.)Emergency situation

Quick management required: Systolic BP must be maintained above 100 mm Hg and, optimally, below 140 mm Hg.

OXYGEN

MORPHINE (IV)

BETA-BLOCKERS & NITRATES (IV)

THROMBOLYTICS

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0 hrs0% damage24 hrs100% damage

ConclusionAngina is chest pain caused by transient myocardial ischemia due to lack of adequate oxygen supply44

Conclusion (cont.)45

Conclusion (cont.)Angina occurs due to narrowing of the coronary arteries by:

Spasm

Plaque

formation 46

Conclusion (cont.)Angina caused by:

Smoking Sedentary life

Unhealthy foods

Alcohol abuse

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Conclusion (cont.)Angina is presented mainly as:

Chest pain that may spread to :Left shoulders

Neck

Arms

Jaws

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Conclusion (cont.)Angina can be diagnosed by:

ECG (stress)

Coronary angiography49

Conclusion (cont.)

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DONT Offer TENS, EECP or acupuncture

Conclusion (cont.)

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Offer vitamin or fish oil supplements

Conclusion (cont.)

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DONT Routinely offer drugs for 2ry prevention to patient with suspected cardiac syndrome X

Conclusion (cont.)

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Conclusion (cont.)Pharmacological Management include:

Beta blockers

calcium channel blockers

Nitrates

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Conclusion (cont.)Pharmacological Management include:

Antiplatelets

Other agents (e.g. Ranolazine )

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Conclusion (cont.)Risk factor modification is the most important No smoking

Limit alcohol

No high saturated fat/high cholesterol foods

Maintain normal blood lipid levels

Maintain blood pressure within normal range

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