Management of Stable Angina Pectoris David Putnam, MD Albany Medical College.

Management of

Stable Angina Pectoris

David Putnam, MD

Albany Medical College

Angina Pectoris

• Classic angina is characterized by substernal squeezing chest pain, occurring with stress and relieved with rest or nitroglycerin.

• May radiate down the left arm

• May be associated with nausea, vomiting, or diaphoresis.

Stable AnginaClassification

• Exertional

• Variant

• Anginal Equivalent Syndrome

• Prinzmetal’s Angina

• Syndrome-X

• Silent Ischemia

Angina: Exertional

• Coronary artery obstructions are not sufficient to result in resting myocardial ischemia. However, when myocardial demand increases, ischemia results.

Angina: Variant Angina

• Transient impairment of coronary blood supply by vasospasm or platelet aggregation

• Majority of patients have an atherosclerotic plaque

• Generalized arterial hypersensitivity

• Long term prognosis very good

Angina: Anginal Equivalent Syndrome

• Patient’s with exertional dyspnea rather than exertional chest pain

• Caused by exercise induced left ventricular dysfunction

Angina: Prinzmetal’s Angina

• Spasm of a large coronary artery

• Transmural ischemia

• ST-Segment elevation at rest or with exercise

• Not very common

Angina: Syndrome X

• Typical, exertional angina with positive exercise stress test

• Anatomically normal coronary arteries• Reduced capacity of vasodilation in

microvasculature• Long term prognosis very good• Calcium channel blockers and beta blockers

effective

Angina: Silent Ischemia

• Very common

• More episodes of silent than painful ischemia in the same patient

• Difficult to diagnose

• Holter monitor

• Exercise testing

Angina: Treatment Goals

• Feel better

• Live longer

Angina: Prognosis

• Left ventricular function

• Number of coronary arteries with significant stenosis

• Extent of jeoporized myocardium

Stable Angina

Risk stratification

• Noninvasive testing

• Cardiac catheterization

Stable AnginaEvaluation of LV Function

• Physical exam

• CXR

• Echocardiogram

Stable AnginaEvaluation of Ischemia

• History

• Baseline Electrocardiogram

• Exercise Testing

CCSC Angina Classification

• 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

Stable AnginaExercise Testing

• The goal of exercise testing is to induce a controlled, temporary ischemic state during clinical and ECG observation

Angina: Exercise TestingHigh Risk Patients

• Significant ST-segment depression at low levels of exercise and/or heart rate<130

• Fall in systolic blood pressure

• Diminished exercise capacity

• Complex ventricular ectopy at low level of exercise

Angina: Exercise TestingLow Risk Group

CASS Registry: 7 year survival

• Less than 1 mm ST depression in Stage III of Bruce Protocol

• Annual mortality: 1.3%

JACC 1986;8:741-8

ECG Treadmill EST in Women

• Higher false-positive rate

• Reduces procedures without loss of diagnostic accuracy

• Only 30% of women need be referred for further testing

Stable AnginaGuidelines for Nuclear EST

Diagnosis/prognosis for CAD

• Non-diagnostic EST

• Abnormal resting ECG

• Negative EST with continued chest pain

• Intermediate probability of disease

Stable AnginaGuidelines for Nuclear EST

Defined CAD

• Post infarct risk stratification

• Risk stratification to determine need for

revascularization ( viability study )

Stable AnginaDipyridamole Nuclear EST

• Near equivalent sensitivity/specificity with symptom-limited nuclear EST

• Most useful in patients who cannot exercise

• Major contraindication is severe bronchospastic lung disease ( consider Dobutamine study )

Appropriateness of Radionuclide Exercise Testing

• Retrospective analysis of 1092 patients• 64% of tests ordered by cardiologists were

indicated• 30% of tests ordered by non-cardiologists

were indicated• Excessive charges from non-indicates tests

were $1,082,400Am J Card 1996;77:139-42

Stable AnginaStress Echo

• Ischemia may cause wall motion abnormalities, no rise of fall in LVEF

• Sensitivity/specificity same as nuclear testing

• May be better in women

Exercise TestingContraindications

• MI—impending or acute• Unstable angina• Acute myocarditis/pericarditis• Acute systemic illness• Severe aortic stenosis• Congestive heart failure• Severe hypertension• Uncontrolled cardiac arrhythmias

Stable AnginaNon-Invasive Evaluation

C oron ary A rte riog rap h y

L V D ys fu n c tion


H ig h R isk

M ed ica l Th erap y

S tab le


R ecu rren t A n g in a

M ed ica l Th erap y

L ow R isk

S tress Tes tin g

N orm a l L V F u n c tion

R es tin g L V F u n c tion(C lin ica l A ssessm en t)

N on d isab lin g A n g in a

Cardiac CatheterizationIndications

• Suspicion of multi-vessel CAD

• Determine if CABG/PTCA feasible

• Rule out CAD in patients with persistent/disabling chest pain and equivocal/normal noninvasive testing

Risk Factor Modification

• Hypertension

• Smoking

• Dyslipidemia

• Diabetes Mellitus

• Obesity

• Stress

• Homocysteine

Stable AnginaTreatment Options

M ed ic in e P ercu tan eou sIn te rva tion

C A B G

A n g in aTrea tm en t O p tion s


• Medical Treatment

Stable AnginaCurrent Pharmacotherapy

• Beta-blockers

• Calcium channel blockers

• Nitrates

• Aspirin

• Statins

• ? ACE inhibitors

Stable AnginaConsiderations when Choosing a Drug

• Effect on myocardium

• Effect on cardiac conduction system

• Effect on coronary/systemic arteries

• Effect on venous capitance system

• Circadian rhytm

Beta-Blockers

• 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

Beta-Blockers

Beta BlockersSide Effects

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

Beta BlockersCommon Available Agents

• Propranolol

• Atenolol

• Metoprolol

• Nadolol

• Timolol

Calcium Channel BlockersMechanisms of Action

• 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

Calcium Channel BlockersMechanisms of Action

Calcium Channel BlockersSide Effects

• Palpitations

• Headache

• Ankle edema

• Gingival hyperplasia

Calcium Channel BlockersAvailable Agents

• Verapamil• Diltiazem• Nifedipine• Nicardipine• Amlodipine• Felodipine• Nisoldipine• Bepridil

NitratesMechanisms of Action

• Nitric oxide has been identified as endothelium-derived relaxing factor

• Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

NitratesMechanisms of Action

• 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

NitratesReducing Tolerance

• 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

NitratesSide Effects

• Headache

• Flushing

• Palpitations

• Tolerance

• To provide optimal benefit to patients, clinicians must use nitroglycerin more systematically and critically than they have before

W. Frischman

NitratesCommon Available Agents

• Isorbide dinitrate

• Isorbide mononitrate

• Long-acting transdermal patches

• Nitroglycerin sl


• CABG


• PTCA

Stable Angina: 1-Vessel CADTherapeutic Strategies

• Initiate pharmacologic treatment

A. Nearly half of patients will become asymptomatic

• PTCA preferred alternative if medical therapy does not relieve angina or causes adverse effects


• Initial medical management in patients with mild ischemic symptoms and normal LV function

• Revascularization in patients who fail medical therapy

• Selection of PTCA vs. CABG depends on coronary anatomy, LV function, need for complete revascularization, and patient preference


• CABG in patients with left-main disease or 3-vessel CAD and decreased LVEF

• PTCA or medical management an alternative in patients with 3-vessel CAD, mild symptoms, and preserved LVEF

Management of Stable Angina Pectoris David Putnam, MD Albany Medical College.

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