1

3rd jan 2009

Done by: Ahmed M. Aljabri Pharm.D

Angina Overview Pathophysiology Types of angina Diagnosis Management Key points

2

Angina pectoris is a medical term for chest pain or discomfort due to coronary heart disease

Angina is a symptom of a condition called myocardial ischemia

It occurs when the heart doesn't get as much blood (hence as much oxygen) as it needs

This usually happens because one or more of the heart's arteries is narrowed or blocked

4

Is the single most common cause of premature death in Europe and in 2020 will be the major cause of death in the world

About 1.3 million person with new cases of angina and 330,000 complicated to myocardial infarction every year

Angina occurs in 1:3 men and 1:4 women

It can be a sign of heart disease, even when initial tests don't show evidence of CAD

Epidemiology :

Risk factors may include :age, male sex, family history, smoking, alcohol, heavy meals, sedentary life stile, hypertension, obesity, lipid disorders, diabetes mellitus, haemostatic factors and physical inactivity

Typical angina is a pain in the centre of the chest

The discomfort also may be felt in the neck, jaw, shoulder, back or arm 

Symptom :

Angina often occurs when the heart needs more blood For example, running to catch a bus could trigger an

attack of angina while walking might not 

Angina may happen during exercise, strong emotions or extreme temperatures

8

1. Stable angina

2. Unstable angina

3. Variant (Prinzmetal's) angina

Knowing how the types are different is important

10

People with stable angina have episodes of chest pain that are Usually predictable Has a regular pattern   Lasting from 0.5 to 30 minutes  

It occurs when the heart is working harder than usual On exertion Under mental or emotional stress

Normally the chest discomfort is relieved with rest, nitroglycerin or both

11

In people with unstable angina, Unexpected chest pain Doesn't follow a pattern More severe and prolonged than typical angina

It can occur with physical exertion or at rest and may relieved by medicine

 

People with new, worsening or persistent chest discomfort should be evaluated in a hospital emergency department and monitored carefully

  Unstable angina is an acute coronary syndrome

and should be treated as an emergency 

12

Chest pain usually Occurs spontaneously Occurs when a person is at rest Very painful and usually occur between midnight and 8

a.m.

It doesn't follow physical exertion or emotional stress

Variant angina is due to transient coronary artery spasm

13

14

Differential Diagnosis of Episodic Chest Pain

Person's medical history and risk factors

Chest X-ray

Electrocardiogram (ECG)

Echocardiography

Cardiac enzymes to role out myocardial infarction

15

The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%

It’s the most accurate test to detect arterial coronary narrowing

Acute myocardial infarction (heart attack)

Severe cardiac arrhythmias

Cardiac arrest leading to sudden death

18

DESIRED OUTCOME(Goals)

The short-term goals of therapy are To reduce or prevent the symptoms of angina that limit

exercise capability and impair quality of life

Long-term goals of therapy are To prevent CHD events such as MI, arrhythmias, and

heart failure and to extend the patient’s life

19

Lifestyle changes

Medicines

Medical procedures

20

Stop smoking and alcohol intake

Physical activities within limits Avoid large meals and rich

foods that leave you feeling stuffed

Control the body weight Control the blood sugar if the

patient is diabetic Control the blood cholesterol

if the patient has a lipid disorder

Avoid stressed You also can make lifestyle changes that help lower your risk of heart disease

22

medications used to treat angina address the myocardial oxygen demand/supply imbalance from a hemodynamic perceptively

23

Treat with drugs

Blood supply to the heart Heart's demand for oxygen

Coronary vasodilators

1.Nitroglycerin

Drugs that reduce blood pressure&

Drugs that slow the heart rate

2.Beta-blockers and

3.calcium antagonists

1.Short-acting nitroglycerin tab (0.3-0.6 up to 1.5 mg)

• Can be repeated at five minute intervals .used in acute attach

• Can also be used prior to exertion to prevent angina• Short term effect;1-7 minspray preparation where each “puff” is 0.4 mg

Nitroglycerin intravenous infusion5-200 micro gm/min; short action require continuous infusion

24

2.Longer-acting nitroglycerin preparations such as;

• Isordil tablets 5-80mg, 2-3times daily•(Nitro-Dur )transdermal systems (patch form)0.2-0.8mg/hrs every 12 hr. •Nitro ointment

All relieves spasm of the coronary arteries and can redistribute coronary artery blood flow to areas that need it most

Side effect : Headache Flushing Hypotension

Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart

Decreases the heart rate Lowers the blood pressure Reduces the pumping force of the heart muscle

All of which reduce the heart muscle's demand for oxygen

26

Beta-blockers are the preferred initial choice, often used in conjunction with an organic nitrate to more positively address the hemodynamic imbalances causing the angina

Cardio selective beta blocker Acebutolol : 200-600mg twice daily Atenolol : 50-200mg/day Bisoprolol: 10mg/day Metoprolol: 50-200mg Nadolol: 40-80mg/day Propranolol :20-80mg twice daily

Side effects : Worsening of asthma Excess lowering of the heart rate and blood pressure Depression

27

If the patient cannot tolerate the beta-blocker or beta-blocker therapy is contraindicated, a calcium channel blocker with or without an organic nitrate can be considered

Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping force of the heart muscleReducing muscle oxygen demand

Calcium channel blockers is the drug of choice in variant angina

28

Calcium channel blockers: Amlodipine :5-10mg OD long duration of action Felodipine :5-10mg OD long duration of action Nicardipine : 20-40 mg three times short duration Nifedipine : immediate release 30-90mg daily short

durationMiscellaneous; Verapamil.: Immediate release 80-160mg (TDS) short

duration {Hypotension,bradycardia, edema, myocardial

depression} Diltiazem :immediate release,30-80mg (QID)

{Hypotension,bradycardia, edema }

Side effects : Swelling of the legs Excess lowering of the heart rate and blood pressure 29

Treatment of choice ; is sublingual nitroglycerin. This therapy is effective for stable, unstable, or variant angina

30

Beta-blockers alone or in conjunction with an organic nitrate

If the beta-blocker therapy is contraindicated or ineffective in preventing angina a calcium channel blocker may be used

Since the combination of a beta-blocker and either verapamil or diltiazem frequently induces undesirable bradycardia

a dihydropyridine is often selected in combination with a beta-blocker

Since stable and unstable angina are nearly always related to coronary artery disease, in addition to anti anginal therapy, patients should be placed on aspirin and, especially if the patient has heart failure or diabetes mellitus

Calcium channel blockers are the preventive treatment of choice for variant angina

Organic nitrates may be added, if needed Beta-blockers are to be avoided since they induce coronary vasospasm

Procedures are used to treat angina

Percutaneous transluminal coronary angioplasty

Laser angioplasty and atherectomy

Coronary artery bypass graft surgery 

Before performing any of these procedures, a doctor must find the blocked part(s) of the coronary arteries

33

A newly developed computerized x-ray scan (ultrafast CT scan) is highly accurate in detecting small amounts of calcium in the plaque of coronary arteries

If an ultrafast CT scan shows no calcium in the arteries, atherosclerotic coronary artery disease is unlikely especially in younger age

Coronary arteries can close after angioplasty, causing recurrent angina or even heart attacks

One way to decrease the risk of coronary artery closure is by deploying stents to keep the arteries open

Newer drug-coated stents are being improved to significantly reduce the rate of artery closure.

Early studies in Europe with Rapamycin-coated stents have resulted in near-zero restenosis rates, which have previously been unprecedented. These stents are now widely available

Angina is one of many causes of chest pain

Angina is chest pain that is a result of inadequate oxygen supply to the heart muscle

Angina can be caused by coronary artery disease or spasm of the coronary arteries

37

ECG, exercise stress test, stress echocardiography, and cardiac catheterization are important in the diagnosis of angina

Treatment of angina includes lifestyle modification, medications, angioplasty, and/or coronary artery bypass surgery

38

• http://www.americanheart.org/presenter.jhtml?identifier=4472

• Joseph T. et-al, PHARMACOTHERAPY, McGraw-Hill Inc., 6th Edition, 2005, Chapter 15, pg.297-320

Leon S.et al, comprehensive pharmacy review, the point inc, 6th Edition,2007,chapter 39,page 786-812.

www.uptodate.com.uptodate 16.3