Management of Angina
Definition
Angina pectoris is a clinical syndrome usually characterized by episodes of pain or pressure in the anterior chest . The cause is usually insufficient coronary blood flow which results in a decreased oxygen supply to meet an increased myocardial demand for oxygen in response to physical exertion or emotional stress.
Types of Angina
1. Stable angina: predictable & consistent pain that occurs on exertion and relieved by rest.
2. Unstable angina or preinfarction or cresendo angina: symptoms occur more frequently and longer than stable angina.
3. Intractable or refractory angina: sever incapacitating chest pain.
4. Variant angina or prinzmetals angina : pain at rest with reversable ST-segment elevation, caused by coronary artery vasospasm.
5. Silent ischemia: objective evidence of ischemia (as ECG changes with a test), but pt report no symptom.
Stable Angina
• Warm Up Angina
• Walk through Angina
Risk Factors
1. Family history of premature coronary artery disease.
2. DM, systemic HTN.
3. Cigarette smoking.
4. Hypercholesterolemia.
5. Others as obesity, increase levels of lipoprotein,fibrinogen, s.triglycerides
Management
• History
• Examination
• Investigations
• Treatment
Non Invasive Investigations
• ECG
• Cardiac Enzymes
• Echocardiography
• Stress ECG (ETT)
• MPI
CT Angiography
Invasive Approach.. Coronary Angiography… When to Perform?
• Survival of sudden cardiac death
• Signs & Symptoms of Heart Failure
• High risk features on non invasive testing
Treatment Goals
• Reduce premature cardiovascular death
• Prevent complications of SIHD including SCD & HF
• Maintain or restore a level of activity, functional capacity
• Completely, or nearly completely, eliminate ischemic symptoms
• Minimize costs of health care by preventing recurrent hospital admissions
Life style Modification
• BMI of 18.5 to 24.9 kg/m2
• Waist circumference less than 102 cm (40 inches) in men and less than 88 cm (35 inches) in women
• Lipid management
• BP control
• Smoking cessation and avoidance of exposure to secondhand smoke
Dietary Modifications
• Low in saturated fat, cholesterol, and trans fat
• High in fresh fruits, whole grains, and vegetables
Reduced sodium intake
Medical Management
• Antiplatelet
- Aspirin
- Clopidogrel
• Statin
• Anti anginals
- Beta Blockers
- Calcium Channel Blockers
- Nitrates
• Antihypertensives
- ACEi/ ARB/ARNI
-Diuretics
Novel Antianginals
• Ranolazine
• Nicorandil
• Ivabradine
• Trimetazidine
Tricardin
Alternative Strategies for Refractory Angina
• Enhanced External Counter Pulsation (EECP)
• Spinal Cord Stimulation
• Transmyocardial revascularization (TMR) may be considered for relief of refractory
Follow UP
• 1st year à 4-6 months
• Afterwards à 6-1 months