History Baseline Electrocardiogram Exercise Testing
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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
Treatment of Chronic Stable Angina Medical Revascularization
PCIACBG
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Medical Treatment
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ANTIPLATELETS BETA BLOCKERS NITRATES CALCIUM ANTAGONIST ACEI
STATINS NEW THERAPIES
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Effect on myocardium Effect on cardiac conduction system Effect
on coronary/systemic arteries Effect on venous capitance system
Circadian rhytm
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1. Aspirin in the absence of contraindications A 2.
Beta-blockers as initial therapy in the absence of
contraindications in patients with prior myocardial infarction or
without prior myocardial infarction A,B 3. ACE inhibitor in all
patients with CAD who also have diabetes and/or LV systolic
dysfunction A 4. LDL-lowering therapy in patients with documented
or suspected CAD and LDL cholesterol >130 mg/dl, with a target
LDL of
Slide 20
1. Clopidogrel when aspirin is absolutely contraindicated 2.
Long-acting non-dihydropyridine calcium antagonists instead of beta
blockers as initial therapy B 3. In patients with documented or
suspected CAD and LDL cholesterol 100129 mg/dl, several therapeutic
options are available: B a. Lifestyle and/or drug therapies to
lower LDL to
Slide 21
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
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Bronchospasm Diminished exercise capacity Negative inotropy
Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia
Increased claudication Hair loss
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Propranolol Atenolol Metoprolol Carvediloll
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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
Nitric oxide has been identified as endothelium-derived
relaxing factor Organic nitrates are therapeutic precursors of
endothelium-derived relaxing factor
Slide 38
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
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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
1. Treatment of hypertension according to Joint National
Conference VI guidelines A 2. Smoking cessation therapy B 3.
Management of diabetes C 4. Comprehensive cardiac rehabilitation
program (including exercise) B 5. LDL-lowering therapy in patients
with documented or suspected CAD and LDL cholesterol 100 mg/dl,
with a target LDL of
Slide 49
Smoking Complete cessation Blood pressure
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CABG
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1. CABG for patients with significant left main coronary
disease A 2. CABG for patients with triple-vessel disease. The
survival benefit is greater in patients with abnormal LV function
(ejection fraction