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Chronic stable angina. Dr Taban Internist & cardiologist. MAGNITUDE OF THE PROBLEM . Lifetime risk of CAD after 40Y: Men = 49% Women =32% 52% cardiac death One of six all death. Stable Angina . The commonest cause is ADVANCED ATHEROSCELEROSIS. Not new onset. Not at rest chest pain. - PowerPoint PPT Presentation
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Chronic stable angina
Dr TabanInternist & cardiologist
MAGNITUDE OF THE PROBLEM Lifetime risk of CAD after 40Y: • Men = 49%• Women =32%
52% cardiac deathOne of six all death
Stable Angina .
Not new onsetNot new onset
Not at rest chest painNot at rest chest pain
The commonest cause isThe commonest cause is ADVANCED ADVANCED ATHEROSCELEROSISATHEROSCELEROSIS
Not new exacerbatedNot new exacerbated
3
Chest pain caused by transient
myocardial ischemia due to an
imbalance between myocardial
oxygen supply and demand.4
Transient Myocardial Transient Myocardial ischemiaischemia
Severe Chest painSevere Chest pain
Myocardial Blood Flow
Myocardial O2 Demands
Fixed threshold angina
Variable threshold angina
Clinical Manifestations
Differential Diagnosis of Chest Pain
• FIXED-THRESHOLD= Angina Caused by Increased Myocardial O2 Requirements
• VARIABLE-THRESHOLD = Angina Caused by Transiently Decreased O2 Supply
• MIXED ANGINA.
Differential Diagnosis of Chest Pain
Physical Examination
Pathophysiology
Noninvasive Testing • Biochemical Tests :Aop-ProB, LPa, LDL(smal dense), LP-PL A, homocysteinInflammation: hsCRP, BNP, Soluble CD4, Risk factors: FBS, HBA1c &…
• Resting Electrocardiogram
• Noninvasive Stress Testing
Resting Electrocardiogram
50% durig pain = NL-ECG
50% between attacks 50% between attacks :: ECG is entirelyECG is entirely NORMALNORMAL
Other : old problemsOther : old problems
Exercise ECG showing typical severe down sloping Exercise ECG showing typical severe down sloping ST ST segmentsegment : :
Anginal pain is often associated with Depression Anginal pain is often associated with Depression of of STST segment segment
Standing 1 min. 3 min. 7 min. 9 min.
Noninvasive Stress Testing
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• Computed Tomography (MSCT):90%=sensitivity 50% = specificity
• Cardiac Magnetic Resonance Imaging
Catheterization, Angiography, and Coronary Arteriography
• SVD = 2VD = 3VD = 25%.• LML = 5 – 10%.• NL-CAG = 15%.
diffuse disease than MI
Natural History of Angina Pectoris and Risk Stratification
Management of Stable Angina(1) identification and treatment of associated diseases that can
precipitate or worsen angina;
(2) reduction of coronary risk factors;
(3) application of general and nonpharmacological methods, with particular attention to adjustments in life style;
(4) pharmacological management;
(5) revascularization by percutaneous catheter-based techniques or by coronary bypass surgery
Stop smokingStop smoking Reduce weightReduce weight
Treat Hypertension , Treat Hypertension , Hypercholestrolimia Hypercholestrolimia
and Diabetes and Diabetes
AVOID AVOID Severe Severe exertionexertion
Heavy mealHeavy meal EmotionsEmotions Cold WeatherCold Weather
General measures
20•Graduated exercise may open new collaterals
Treatment of an acute attack of anginaSublingualSublingual nitroglycerin nitroglycerin (0.5 mg ) or isosorbide (0.5 mg ) or isosorbide
dinitrate (5 mg ) dinitrate (5 mg ) or Oral sprayOral spray nitroglycerinnitroglycerin (0.4 mg/metered (0.4 mg/metered
dose), dose), isosorbide dinitrateisosorbide dinitrate(1.25 mg/metered (1.25 mg/metered dose) dose)
Relief within 1-3 min. Persistence of pain
Repeat nitroglycerin at 5 min. Repeat nitroglycerin at 5 min. interval (3 tab. max.)interval (3 tab. max.)
Relief not relieved
InfarctionHOSPITALIZATION
What are the antianginal drugs?
Organic nitrates.
Calcium channel blockers.
- adrenoceptor blockers.
-blocker + Long
acting Nitrate
-blocker +
Nifedipine/amilodipin
Verapamil or Diltiazem +
Nitrate
-blocker + Nitrate +
Nifedipine/amilodipin
????
??
??
Anti-platelet
• ASPIRIN
• CLOPIDOGREL
Rx for Risk factors
• HTN
• DM
• HLP - statins
• ACE-Inh:
Management of Variant Angina
Nitrates andNitrates and/or /or Ca-Ca- Channel Channel blockersblockersFor the acute attack & prophylaxisFor the acute attack & prophylaxis
Beta-Blocker?Beta-Blocker?
ASA?ASA?
For patients not responding to adequate medical For patients not responding to adequate medical therapy:therapy:
•Percutaneous Transluminal coronary Percutaneous Transluminal coronary Angioplasty (PTCA)Angioplasty (PTCA)
•Coronary artery bypass grafting (CABG)Coronary artery bypass grafting (CABG)
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