MANAGEMENT OF STABLE ANGINA- THE BASICS

Dr Jayachandran Thejus

Coronary artery disease- Block in coronary

artery due to plaque or thrombus

Leads to myocardial ischemia manifested as chest discomfort

Two types- Plaque- stable angina Thrombus- acute

coronary syndrome

Stable angina- Obstructive plaque Blood flow enough at

rest Blood flow is

inadequate when heart muscle needs extra blood as during exercise or emotional stress

Angina on exertion or emotion

Stable angina means exertional chest discomfort due to a fixed stenosis in a coronary artery.

How to diagnose whether a person with chest discomfort has coronary artery disease or not? Assess the

probability Typical nature

of pain Age Male sex Risk factors

Low probability- no tests

Intermediate probability- TMT or alternate tests

High probability- coronary angiography

Intermediate probability- which test to choose?

Treadmill exercise test or TMT

TMT is not possible Pt cannot exercise LBBB, WPW, pacemaker, resting ST

depression, digitalis SPECT CT angiography

SPECT

Radioactive technitium is injected IV at stress and at rest

Radioactivity from various areas of the heart is measured.

Perfusion defect during stress indicates ischemic myocardium.

Can be done with adenosine IV in patients who cannot exercise

CT coronary angiography

Negative predictive value is high.

Positive predictive value is low.

Useful to rule out CAD in low risk patients.

If positive, does not mean that stenosis is present. ICA is needed.

Invasive coronary angiography- Intermediate probability- Stress test

positive High probability

Typical angina RWMA by echo Low EF by echo

Patient presents with chest pain. You evaluate the patient and find the

probability of having CAD. Low probability- follow-up. Intermediate probability- TMT. If

positive- angiography. High probability- angiography

Angiography- No plaques- no

treatment Non-obstructive

coronary plaques- medical management

Obstructive coronary plaques- Small vessel- Medical

management Large vessel- PCI or

CABG

Coronary stenosis- Single vessel- PCI Multivessel- SYNTAX score

<22- PCI 22 to 32- PCI or CABG >/= 33-CABG

Left main- Ostial or mid- PCI Distal- CABG

Lifestyle modification

Smoking cessation Most effective lifestyle change Nicotine gum and bupropion can be

given Diet

Decrease saturated fatty acids Increase PUFA- fish Increase fruit and vegetable intake Decrease total energy intake to keep BMI

< 25

Regular physical activity Aerobic activity like walking is preferred Intensity depends on cardiac status

Sexual activity PDE5 inhibitor has interaction with

nitrates Weight reduction Sleep apnoea evaluation

LDL Reduce by > 50%

BP Keep < 140/90 mm Hg

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Aspirin 75 to 150 mg/day.

If intolerant, clopidogrel.

Do not add aspirin to clopidogrel.

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Statin always needs to be added.

LDL has to be reduced by more than 50% of basline value.

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

ACEI to improve prognosis in HT DM CKD EF 40% or less

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Sublingual nitrate SOS 5 mg ISDN 0.5 mg NTG

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Beta-blocker Any cardioselective

beta-blocker Do not combine

with non-DHP Ca CB Include to improve

prognosis in post MI and HF.

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

CaCB Non-DHP

Verapamil Diltiazem

DHP Long acting nifedipine Amlodipine

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Long acting nitrate If frequent angina 10 mg ISDN TDS or

30 – 60 mg ISMN bid or controlled release NTG 2.6 or 6.4 mg bid

Try to avoid CaCB or alpha blocker

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Ranolazine 500 to 1000 mg bid Most trial data

among alternative drugs

No effect on BP or heart rate

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Ivabradine 5 to 7.5 mg bid If rate is

uncontrolled even after b B optimum dose

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Nicorandil 5 to 10 mg bid

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

Trimetazidine 35 mg bid

Pharmacological treatment- To improve long term

prognosis Aspirin Statin

To relieve angina S/L nitrate SOS If angina is frequent- b B

or Ca CB or both Is still no relief- long

acting nitrate or other drugs

EECP Spinal cord

stimulation Chelation

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