l3 angina alazhar 8 12 2014

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Definition

Types of Angina

Management of Angina

Antianginal drugs

Transient Myocardial Transient Myocardial ischemiaischemia

Severe Chest painSevere Chest pain

Myocardial Blood Flow

Myocardial O2 Demands

Angina Pectoris

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Chest pain caused by transient myocardial ischemia

due to an imbalance between myocardial oxygen

supply and demand.

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It is manifested as a heavy, compressing or crushing retrosternal pain or discomfort radiating to the left shoulder, flexor aspect of the left arm, jaw or epigastrium.

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Pulmonary embolism

A lung infection

Aortic dissection

Aortic stenosis

Hypertrophic cardiomyopathy

Pericarditis

Types of AnginaTypes of Angina1. Stable Angina (classical, typical).

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2. Unstable Angina.

3. Variant Angina.

4. Microvascular Angina.

Other Names for Angina

• Angina pectoris • Acute coronary syndrome • Chest pain • Acute coronary disease• Coronary artery spasms • Prinzmetal's angina• Stable or common angina • Unstable angina • Variant angina

Types of Angina

• Chronic stable angina (also called classic or effort angina)

• Unstable angina(also called preinfarction or crescendo angina)

• Vasospastic angina(also called Prinzmetal’s or variant angina)

Types of Angina4 types1.Stable

most commonhas common patternoccurs during exercisedecreases at resttreatable

2.Unstableno patternnot relieved by rest/medicinepreclude to heart attack

3.Variant (or Prinzmetal’s)rareoccurs at rest between midnight and early morningRelieved by medicine

4- microvascular More severe and last longer than other type of

angina Medicine may not relive this type of angina

Stable Angina SymptomsStable Angina Symptoms• Occurs when the heart must work harder, usually Occurs when the heart must work harder, usually

during physical exertion during physical exertion • Doesn't come as a surprise, and episodes of pain Doesn't come as a surprise, and episodes of pain

tend to be alike tend to be alike • Usually lasts a short time (5 minutes or less) Usually lasts a short time (5 minutes or less) • Is relieved by rest or medicine Is relieved by rest or medicine • May feel like gas or indigestion May feel like gas or indigestion • May feel like chest pain that spreads to the arms, May feel like chest pain that spreads to the arms,

back, or other areas back, or other areas

Unstable Angina SymptomsUnstable Angina Symptoms • Often occurs at rest, while sleeping at night, or Often occurs at rest, while sleeping at night, or

with little physical exertion with little physical exertion • Comes as a surprise Comes as a surprise • Is more severe and lasts longer (as long as 30 Is more severe and lasts longer (as long as 30

minutes) than episodes of stable angina minutes) than episodes of stable angina • Is usually not relieved with rest or medicine Is usually not relieved with rest or medicine • May get continually worse May get continually worse • May mean that a heart attack will happen soon May mean that a heart attack will happen soon

Variant Angina SymptomsVariant Angina Symptoms • Usually occurs at rest and during the night Usually occurs at rest and during the night

or early morning hours or early morning hours • Tends to be severe Tends to be severe • Is relieved by medicine Is relieved by medicine

1.1. Stable Angina (classical, typical).

Retrosternal painRetrosternal pain

Radiating to left arm & Radiating to left arm & shouldershoulder

The commonest cause isThe commonest cause is ADVANCED ATHEROSCELEROSISADVANCED ATHEROSCELEROSIS

Lasting less than 15 min.Lasting less than 15 min.12

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have episodes of chest discomfort that are usually predictable ,such as on exertion or under stress

ExertionExertionEmotionEmotion

Heavy mealsHeavy mealsExposure to cold Exposure to cold

weatherweather

Predisposing factors Relieving factors

Stable Angina

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RestRest

sublingual nitroglycerin, Beta blockers

2.2. Unstable Angina .

Myocardial infarction may occur in 10-20% of patients.Myocardial infarction may occur in 10-20% of patients.

N.B.N.B. Pain occurs with less exertion or at rest Pain occurs with less exertion or at rest

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the chest pain is unexpected and usually the chest pain is unexpected and usually occurs while at rest.  The discomfort may occurs while at rest.  The discomfort may be more severe and prolonged than be more severe and prolonged than typical anginatypical angina

3.3. Variant Angina .(Prinzmetal)

Chest pain at rest due to Chest pain at rest due to coronary artery spasmcoronary artery spasm

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The list of risk factors mentioned for Angina in various sources includes-:

1 - Smoking 2 - Obesity

3 - High saturated fat diet 4 - High salt diet 5 - Hypertension

6 - Atherosclerosis 7 - Diabetes 8 - Inactivity

9 - Stress 10 -Menopause

11 - Family history of coronary artery disease

Management of Angina

Management of Stable Angina

Management of Unstable Management of Unstable AnginaAngina

Management of Variant Angina

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Management of Stable Angina

1- 1- General measures.General measures.

2- 2- Drug Treatment.Drug Treatment.

3- 3- Coronary artery Coronary artery revascularization.revascularization.

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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

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•Graduated exercise may open new collaterals

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Treatment of an acute attack of anginaSublingualSublingual nitroglycerin nitroglycerin or isosorbide dinitrate or isosorbide dinitrate

or Oral sprayOral spray nitroglycerinnitroglycerin, , isosorbide dinitrateisosorbide dinitrate

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

InfarctionHOSPITALIZATION21

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Management of Unstable AnginaNitrateNitrate

++Aspirin (low dose) and/orAspirin (low dose) and/or

Heparin orHeparin orThrombolytic (stryptokinase)Thrombolytic (stryptokinase)to minimize risk of infarctionto minimize risk of infarction

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Management of Variant Angina

Nitrates andNitrates and/or /or Ca++Ca++ Channel blockersChannel blockers

For the acute attack & For the acute attack & prophylaxisprophylaxis

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What are the antianginal drugs?

Organic nitrates.

Calcium channel blockers.

- adrenoceptor blockers.

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NITRATESNITRATES

VeinsVeins

ArteriesArteries

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Relaxation of smooth Relaxation of smooth muscles Dilatationmuscles Dilatation

Cellular Mechanism of Vasodilatation

NitratesNitrates Formation of Formation of Nitric oxide (NO)Nitric oxide (NO)

Activation of Activation of Guanylate cyclaseGuanylate cyclase

Synthesis of Synthesis of cyclic GMPcyclic GMP

Relaxation of Vascular Relaxation of Vascular smooth musclessmooth muscles

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N.B. (-SH) groups are required for formation of NO.

Adverse Reactions :Adverse Reactions :1- Postural Hypotension 1- Postural Hypotension

orthostatic hypotension & & SyncopeSyncope

2- Tachycardia2- Tachycardia

5- Throbbing Headache5- Throbbing Headache

4- Facial Flushing4- Facial Flushing

3- Drug Rash3- Drug Rash

6- Prolonged high dose 6- Prolonged high dose MethaemoglobinaemiaMethaemoglobinaemia

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How does it occur?

The main limitation of chronic nitrate therapy is

TOLERANCE

It develops as SH groups in vessel wall become oxidized by constant exposure to nitrates, this prevents the production of NO & hence stimulation of Guanylate cyclase which is believed to be fundamental to smooth muscle relaxation produced by the drugs.

Tolerance to the antianginal effect occurs as a result of chronic administration

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“NITRATE FREE INTERVAL” of 8-10 hrs reduces or prevents development of nitrate tolerance.e.g. isosorbide dinitrate is given at 7am, noon and 5pm; trnsdermal patches should be used for about 12 hrs daily

-blockers are effective in STABLE angina

In contrast they are not useful for

vasospastic angina (Variant) {Prinzmetal}& may worsen the condition. This deleterious effect is likely due to an increase in coronary resistance caused by the unopposed effects of catecholamines acting at -adrenoceptors.

The effectiveness of The effectiveness of -adrenoceptor blockers in the -adrenoceptor blockers in the treatment of exertional angina is attributable to a fall treatment of exertional angina is attributable to a fall in myocardial Oin myocardial O22 requirement at rest & during requirement at rest & during exertion due to :exertion due to :

1- A -ve chronotropic effect (particularly during 1- A -ve chronotropic effect (particularly during exercise).exercise).

2- A -ve inotropic effect. 2- A -ve inotropic effect.

3- A reduction in arterial blood pressure (particularly 3- A reduction in arterial blood pressure (particularly systolic pressure) during exercise.systolic pressure) during exercise.

Mechanism of antianginal action:Mechanism of antianginal action:

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Adverse ReactionsAdverse Reactions : :

CHFCHF A-V blockA-V block BronchospasmBronchospasm

Cold Cold extremitiesextremities Worsening Worsening

symptoms of PVDsymptoms of PVDHypotensionHypotension

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CHFCHF A-V blockA-V block

Peripheral Peripheral Vascular Vascular diseasedisease

HypotensionHypotension

Contraindications :Contraindications :

Bronchial Bronchial asthmaasthma

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Verapamil

Diltiazem

Dihydropyridine group

Nifedipine

Amlodipine

Used in treatment of all types of angina.

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Mechanism of anti-anginal action :Mechanism of anti-anginal action :

1 - Coronary artery dilatation and relief of coronary spasm (variant angina)

•(Verapamil & Diltiazem)

•Decrease HR.

•Decrease contractility

•Decrease AV conductivity

•Arteriolar dilatation

Vascular resistance Afterload

2 -Decrease myocardial O2 demand due to:

Adverse reactions :Adverse reactions :

DizzinessDizzinessAnkle Ankle edemaedema HypotensionHypotensionHeadacheHeadache

FlushingFlushingConstipationConstipation

A-V block & HF A-V block & HF onlyonly with Verapamil & with Verapamil &

DiltiazemDiltiazem

Reflex Reflex Tachycardia Tachycardia

with Nifedipinewith Nifedipine