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chronic stable angina

Commonly, referenced as angina. Etiology: 1) coronary artery disease - cardiovascular risk factors 2) aortic stenosis 3) hypertrophic cardiomyopathy 4) pharmaceutical causes: (exacerbation) - alpha blockers - beta blocker withdrawal - ergotamine - hydralazine - methysergide - minoxidil - nifedipine - oxytocin - thyroxine (excessive) - vasopressin Pathology: - myocardial ischemia secondary to reduced blood flow through partially obstructed coronary arteries Epidemiology: 1) 5-7% of population from 44 to 75 years of age 2) risk increases with age Clinical manifestations: 1) steady precordial pressure or pain 2) induced by exercise, emotion, or eating - at least 2 months duration [1] 3) radiation to the jaw or left shoulder & arm 4) duration of pain < 20 minutes 5) dyspnea, especially female, diabetic, elderly 6) diaphoresis 7) fear of death 8) nausea 9) relief by nitroglycerin or rest 10) palpable precordial apical bulge that disappears with pain 11) signs of congestive heart failure (CHF) may be present 12) 4th heart sound 13) mitral regurgitant murmur secondary to papillary muscle dysfunction Laboratory: - fasting lipid panel Special laboratory: - electrocardiogram (ECG): a) ST segment depression during pain b) T wave changes (inversion) during pain c) Q waves suggest prior MI - exercise treadmill a) able to exercise 2) normal ECG or non-interfering ECG changes - complete RBBB ok - echocardiogram: a) previous MI, or Q waves on ECG b) heart failure - LBBB not ok - exercise echocardiography a) pre-excitation (WPW) b) LBBB c) ST segment depression > 1 mm d) previous revascularization Radiology: 1) stress tests a) graded exercise test with or without thallium or sestamibi scintigraphy b) dipyridamole thallium test or dobutamine echocardiogrqphy 1] severe arthritis 2] morbid obesity 3] stroke 4] peripheral arterial disease 5] pacemaker: electronically paced ventricular rhythm c) patients with stable angina with good exercise tolerance are low risk unless imaging demonstrates left main coronary artery disease or multivessel coronary artery disease [22] 2) coronary CT angiography may useful in emergency department setting* a) lessens need for coronary angiography in intermediate risk patients with chest pain [15] b) associated with lower risk for myocardial infarction but not mortality compared with exercise stress testing [16] c) improved clinical outcomes at 5 years in patients with chest pain [17] 3) coronary angiography & percutaneous coronary intervention (PCI)* a) LV dysfunction b) NYHA class 3 or class 4 angina, despite optimal therapy [1] c) positive stress test or uncertain diagnosis after stress test d) high probability of left main coronary artery or 3-vessel disease e) survivors of sudden cardiac death f) suspected coronary vasospasm (Prinzmetal's angina) g) does not decrease mortality or risk for MI [1] 4) multidetector CT shows promise [5] * no significant differences between CT angiography & coronary angiography with PCI in cardiovascular-related death, myocardial infarction, or stroke during 3 1/2 year follow-up [21] Differential diagnosis: see chest pain Complications: - women with angina pectoris, but mild or no obstruction on angiography, are not clear of cardiovascular risk [6] Management: 1) general - patients with stable angina with good exercise tolerance are low risk unless imaging demonstrates left main coronary artery disease or multivessel coronary artery disease [22] 2) risk factor (life style) modification a) smoking cessation reduces risk of coronary artery disease by 50% within 5 years of quitting b) aerobic exercise c) weight loss: maintenance of ideal body weight reduces risk of coronary artery disease d) control of hypertension - BP < 140/90, 130/80 if diabetic e) control of diabetes - include SGLT2 inhibitor (flozin) or GLP1-receptor agonist (glutide) [1] f) dietary intervention - reduction in calories - reduction in total & saturated fat - reduction in cholesterol - reduction in sodium may be appropriate - antioxidants have been suggested to have benefit - Mediterranean diet, DASH diet 3) pharmaceutical agents a) beta-adrenergic receptor antagonists (all patients) 1] decrease heart rate & myocardial contractility - achieve heart rate of 55-60/min 2] useful in exercise-induced angina 3] cardioselective beta blockers are preferred agents (not according to NEJM) [22] a] atenolol b] metoprolol c] no need to replace carvedilol with metoprolol [22] 4] contraindications a] asthma b] symptomatic bradycardia c] heart failure d] severe peripheral arterial disease b) aspirin (all patients) 1] 75 to 325 mg QD 2] effective in secondary prevention of coronary artery disease in patients with angina 3] clopidogrel if aspirin intolerant c) nitrates 1] beta-blocker not sufficient to relieve symptoms 2] reduce preload & afterload 3] dilate coronary arteries 4] daily nitrate free interval of 8-10 hours 5] may cause headaches 6] sublingual nitroglycerin 7] isosorbide (long-acting) 8] transdermal nitrates d) calcium channel blocker 1] beta-blocker cannot be used or is not sufficient to relieve angina 2] increase coronary artery perfusion 3] diminish afterload 4] diltiazem or verapamil suggested except if LV systolic dysfunction [1] - amlodipine ok for relief of angina 5] do not use short-acting calcium channel blocker (nifedipine ..) [1] e) ACE inhibitor [1] 1] LV ejection fraction < 35% 2] stroke, CAD, or peripheral artery disease - no proven value in chronic stable angina 3] diabetes, chronic renal failure 4] additional cardiac risk factors - history of myocardial infarction - calcium channel blocker in use f) statin (all patients) 1] target LDL < 100 mg/dL 2] clinical factors may stratify risk to identify patients for high-dose statins [7] g) ranolazine if other options exhausted [1,9] - calcium channel blocker in use 4) adjunctive therapy with acupuncture may be of benefit [20] 5) revascularization for persistent symptoms despite maximal medical therapy [1] a) percutaneous transluminal angioplasty - improves quality of life [1] - does not improve survival or reduce cardiovascular events b) coronary artery bypass graft (CABG) - reduces of mortality (RR=0.80), myocardial infarction, & need for subsequent revascularization, compared with medical management [13] - CABG preferred to PCI for left main with LV systolic dysfunction or 3-vessel disease or multivessel disease with diabetes mellitus [1] 6) refractory angina pectoris not amenable to revascularization a) enhanced external counterpulsation b) spinal cord stimulation of the region that receives cardiac nerve fibers diminishes angina & improves functional status [1] 7) routine screening in asymptomatic patients not indicated [1]

Related

acute coronary syndrome; unstable angina (ACS) Prinzmetal's angina; variant angina; coronary vasospasm

General

angina pectoris chronic heart disease

References

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