Angina pectoris Domina Petric MD Introduction Angina pectoris

Angina pectoris Domina Petric, MD

Introduction Angina pectoris (AP) is due to myocardial ischaemia. AP presents as a central chest tightness or heaviness. Symptoms are brought on by exertion and relieved by rest.

Introduction Pain may radiate to one or both arms, the neck, jaw or teeth.

Precipitating factors physical exertion emotion cold weather heavy meals

Associated symptoms dyspnoea nausea sweatiness faintness

Causes atherosclero sis, atheroma anemia aortic stenosis tachyarrhythmia s hypertrophic cardiomyopathy arteritis or small vessel disease (microvascular angina, cardiac syndrome x)

Types of angina Stable angina is induced by effort, relieved by rest. Unstable (crescendo) angina is angina that is of increasing frequency or severity and occurs on minimal exertion or at rest. Unstable angina is associated with high risk of myocardial infarction.

Types of angina Decubitus angina is precipitated by lying flat. Variant (Prinzmetal´s angina) is caused by coronary artery spasm. Prinzmetal´s angina may coexist with fixed stenosis.

Stable angina Lumen of blood vessel is narrowed by plaque. There is inappropriate vasoconstriction.

Unstable angina Plaque is ruptured. There is platelet aggregatio Thrombus formation! Unopposed vasoconstricti

Variant angina Prognosis is very good. No overt plaques. Intense vasospas m!

Prinzmetal angina This is due to coronary artery spasm which can occur even in normal coronary arteries. Pain occurs during rest rather than during activity. ECG: ST segment elevation is present during pain, but usually resolves as the pain subsides.

Image source: WIKIWAND Tranzient ST elevation during pain in Prinzmetal´s a

Prinzmetal angina Treatment: calcium channel blockers with or without longacting nitrates. Aspirin can aggravate the ischaemic attacks in these patients. Beta-blockers should be avoided because they can increase

ECG in stable angina It is usually normal. There may be ST depression, flat or inverted T waves, eventually signs of past myocardial infarction.

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ST depression Planar (horizontal) or downsloping ST segment depression of one millimeter or more is indicative of ischemia. Up-sloping ST segment depression is less specific and it is often found in normal heart.

It is very important to exclude precipitating factors during diagnostics of AP: anaemia diabetes hyperlipidaemia thyrotoxicosis temporal arteritis

II. MANAGEMENT

Modifying risk factors smoking cessation weight loss moderate exercise lowering arterial blood pressure control of blood sugar and lipemia

Aspirin in dose 75 -150 mg a day can reduce mortality rate by 34%. Aspirin is contraindicated in Prinzmetal angina.

Beta-blockers Atenolol (for example) 50 -100 mg a day per os can reduce symptoms. BB are contraindicated in asthma, COPD, left ventricular failure, bradycardia and coronary artery spasm (like in variant angina).

Nitrates Spray or sublingual tablets up to every half an hour for symptoms relief. Nitrates can be used for prophylaxis: isosorbide mononitrate 20 -40 mg per os twice a day. It is very important to achieve an 8 hours nitrate free period to prevent tolerance.

Nitrates Alternative for prophylaxis are slowrelease nitrates, adhesive nitrate skin patches and buccal pills. Common nitrates side effects are headaches and hypotension. Nitrates are contraindicated if blood pressure is below 90/60 mm. Hg.

Long acting calcium antagonists Amplodipine 10 mg/24 h Diltiazem 90 -180 mg/12 h

Ivabradine inhibits the pacemaker current in the SA node. Ivabradine reduces heart rate. It can be usefull in patents that can not take beta blockers for some reason.

Other drugs Trimetazidine inhibits fatty acid oxidation. Ranolazine inhibits the late sodium current. Nicorandil is potassium channel activator.

Indications for hospital admission new angina of sudden onset recurrent angina in patients with past myocardial infarction or CABG angina uncontrolled by drugs unstable angina

Percutaneous transluminal coronary angioplasty (PTCA) PTCA involves balloon dilatation of the stenotic vessels.

Indications for PTCA poor response or intolerance to medical therapy refractory angina in patients not suitable for CABG previous CABG post-thrombolysis in patients with severe stenoses, symptoms or positive stress tests

Benefits of PTCA Early intervention may benefit high risk patients presenting with non-ST segment elevation myocardial infarction. Stenting reduces restenosis rates.

Complications of PTCA restenosis (20 -30% within 6 months) emergency CABG (<3%) myocardial infarction (<2%) death (<0, 5%)

Thrombosis prevention Antiplatelet agents (clopidogrel) reduce the risk of stent thrombosis. Iv. glycoproteins IIb/IIIa inhibitors (eptifibatide) reduce procedurerelated ischaemic events. Drug-coated stents reduce restenosis rate, but increase risk of late in-stent thrombosis.

Literature: Oxford Handbook of Clinical Medicine. Longmore M. Wilkinson I. B. Baldwin A. Elizabeth W. Ninth edition. Wikiwand http: //book-med. info