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Feel better Live longer

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To improve quality of life (symptoms) To reduce mortality To reduce morbidity To reduce progression of disease and induce regression.

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Left ventricular function Number of coronary arteries with significant stenosis Extent of jeoporized myocardium

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Risk stratification Noninvasive testing Cardiac catheterization

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Physical exam CXR Echocardiogram

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History Baseline Electrocardiogram Exercise Testing

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Class I Class II Class III Class IV Angina only with extreme exertion Angina with walking 1 to 2 blocks Angina with walking 1 block Angina with minimal activity

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Hypertension Smoking Dyslipidemia Diabetes Mellitus Obesity Stress Homocysteine

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Treatment of Chronic Stable Angina Medical Revascularization PCIACBG

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Medical Treatment

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ANTIPLATELETS BETA BLOCKERS NITRATES CALCIUM ANTAGONIST ACEI STATINS NEW THERAPIES

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Effect on myocardium Effect on cardiac conduction system Effect on coronary/systemic arteries Effect on venous capitance system Circadian rhytm

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1. Aspirin in the absence of contraindications A 2. Beta-blockers as initial therapy in the absence of contraindications in patients with prior myocardial infarction or without prior myocardial infarction A,B 3. ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic dysfunction A 4. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol >130 mg/dl, with a target LDL of

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1. Clopidogrel when aspirin is absolutely contraindicated 2. Long-acting non-dihydropyridine calcium antagonists instead of beta blockers as initial therapy B 3. In patients with documented or suspected CAD and LDL cholesterol 100129 mg/dl, several therapeutic options are available: B a. Lifestyle and/or drug therapies to lower LDL to

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Decrease myocardial oxygen consumption Blunt exercise response Beta-one drugs have theoretical advantage Try to avoid drugs with intrinsic sympathomimetic activity First line therapy in all patients with angina if possible

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Bronchospasm Diminished exercise capacity Negative inotropy Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia Increased claudication Hair loss

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Propranolol Atenolol Metoprolol Carvediloll

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Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Improved subendocardial perfusion Slowing of heart rate with diltiazem, verapamil

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Palpitations Headache Ankle edema Gingival hyperplasia

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Verapamil Diltiazem Nifedipine Nicardipine Amlodipine Felodipine Nisoldipine Bepridil

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Nitric oxide has been identified as endothelium-derived relaxing factor Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

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Venous vasodilation/pre-load reduction Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Antiplatelet and antithrombotic effects

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Smaller doses Less frequent dosing Avoidance of long-acting formulations unless a prolonged nitrate-free interval is provided Build-in a nitrate-free interval o 8-12 hours

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Headache Flushing Palpitations Tolerance

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Isorbide dinitrate Isorbide mononitrate Long-acting transdermal patches Nitroglycerin sl

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1. Treatment of hypertension according to Joint National Conference VI guidelines A 2. Smoking cessation therapy B 3. Management of diabetes C 4. Comprehensive cardiac rehabilitation program (including exercise) B 5. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol 100 mg/dl, with a target LDL of

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Smoking Complete cessation Blood pressure

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CABG

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1. CABG for patients with significant left main coronary disease A 2. CABG for patients with triple-vessel disease. The survival benefit is greater in patients with abnormal LV function (ejection fraction