ANGINA PECTORIS

Angina pectorisAngina pectoris ((chest pain)chest pain)

is the result of myocardial is the result of myocardial ischemia caused by an ischemia caused by an imbalance between myocardial imbalance between myocardial blood supply and oxygen blood supply and oxygen demanddemand

EpidemiologyEpidemiology ofof angina pectorisangina pectoris:

Approximately 9.8 million Americans are Approximately 9.8 million Americans are

estimated to experience angina annually, estimated to experience angina annually,

with 500,000 new cases of angina occurring with 500,000 new cases of angina occurring

every year.every year.

Mortality/Morbidity:Mortality/Morbidity:

About every 25 seconds, About every 25 seconds,

an American will have a an American will have a coronary event,coronary event,

and about every minute and about every minute someone will die from one. someone will die from one.

ETIOLOGYETIOLOGY OFOF ANGINA PECTORISANGINA PECTORIS

The main causesThe main causes ofof angina pectoris areangina pectoris are

atherosclerosisatherosclerosis of of thethe coronary artercoronary arteriesies

spasm spasm of the coronary arteriesof the coronary arteries

Major risk factors Major risk factors for angina includefor angina include

cigarette smoking,cigarette smoking, diabetes, diabetes, high cholesterol,high cholesterol, high blood pressure, high blood pressure, sedentary lifestylesedentary lifestyle,, family history of family history of

premature heart premature heart disease.disease.

The New York Heart Association The New York Heart Association classificationclassification

Class IClass I - No limitation of physical activity (Ordinary physical - No limitation of physical activity (Ordinary physical activity does not cause symptoms.)activity does not cause symptoms.)

Class IIClass II - Slight limitation of physical activity (Ordinary physical - Slight limitation of physical activity (Ordinary physical activity does cause symptoms.)activity does cause symptoms.)

Class IIIClass III - Moderate limitation of activity (Patient is comfortable - Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.)at rest, but less than ordinary activities cause symptoms.)

Class IVClass IV - Unable to perform any physical activity without - Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be discomfort, therefore severe limitation (Patient may be symptomatic even at rest.) symptomatic even at rest.)

Unstable anginaUnstable angina is defined as new-onset angina (ie, within 2 is defined as new-onset angina (ie, within 2 mo of initial presentation) of at least class III severity, mo of initial presentation) of at least class III severity, significant recent increase in frequency and severity of angina, significant recent increase in frequency and severity of angina, or angina at rest.or angina at rest.

SymptomsSymptoms andand signssigns

Angina is usually felt as:Angina is usually felt as: pressure,pressure, heaviness,heaviness, tightening,tightening, squeezing, orsqueezing, or aching across the chest, aching across the chest,

particularly behind the particularly behind the breastbone.breastbone.

AnginaAngina is precipitated by exertion, eating, is precipitated by exertion, eating, exposure to cold,exposure to cold, or emotional stress. or emotional stress.

SymptomsSymptoms andand signssigns

This pain often radiates to the This pain often radiates to the neck, neck, jaw, jaw, arms, arms, back, back, or even the teeth.or even the teeth.

Angina lasts a few minutesAngina lasts a few minutes (1-5 (1-5

minutesminutes))

TREATMENT OF ANGINA PECTORISTREATMENT OF ANGINA PECTORIS

The main goals of treatment in angina The main goals of treatment in angina pectoris arepectoris are

to relieve the symptoms, slow the progression of disease, and reduce the possibility of future events,

especially MI and premature death.

TREATMENT OF ANGINA PECTORISTREATMENT OF ANGINA PECTORIS

Modification of risk factors (smoking, BP, lipids) Beta blockers Nitroglycerin Calcium channel blockers ACE Inhibitors Antiplatelet drugs Statins

The goals of pharmacotherapy are The goals of pharmacotherapy are to reduce morbidity and to prevent to reduce morbidity and to prevent

complications.complications.

PHARMACOTHERAPYPHARMACOTHERAPY OF OF ANGINA PECTORIS ANGINA PECTORIS

Nitroglycerin is a potent smooth-muscle relaxant and vasodilator.

Sublingual NitroglycerinNitroglycerin is given for an acute attack or for prevention before exertion. 

0.3–0.6 mg q 4–5 min up to 3 doses. Dramatic relief usually occurs within 1.5 to 3 min, is

complete by about 5 min, and lasts up to 30 min. Patients should always carry  NitroglycerinNitroglycerin  tablets or

aerosol spray to use promptly at the onset of an angina attack. 

Beta-adrenergic blocking agents

Reduce myocardial oxygen consumption via several effects, including decrease in resting and exercise heart rates and reductions in myocardial contractility and afterload.

Classified as nonselective, beta-1 selective, and having intrinsic sympathomimetic effects.

Beta-adrenergic blocking agents

Metoprolol. Selective beta1-adrenergic receptor blocker. Initial: 100 mg/day divided q12hr PO, мay be increased at weekly or longer intervals, effective dosage range 100-400 mg/day PO divided q12hr, no more than 400mg/day.

Atenolol. Selectively blocks beta-1 receptors with little or no effect on beta-2 receptors. Dosing and Uses: 50 mg PO qDay; may increase to 100 mg PO qDay after 1 week; some patients may require 200 mg/day.

Beta-adrenergic blocking agents Bisoprolol. Selective beta1-adrenergic receptor

blocker. Dosing and Uses: 2.5–5 mg po once/day, increasing to 10–15 mg once/day depending on heart rate and BP response.

Propranolol. Nonselective beta-blocker. Dosing and Uses: 80-320 mg PO divided q6-12hr.

Carvedilol. Nonselective beta-blocker. Dosing and Uses: 25 mg po bid (in patients with heart failure or other hemodynamic instability, the starting dose should be as low as 1.625–3.125 mg bid and increased very slowly as tolerated)

Calcium channel blockersCalcium channel blockersIndicated when symptoms persist despite treatment

with beta-blockers or when beta-blockers are contraindicated.

Amlodipine. Initial: 5-10 mg PO qDay.

Diltiazem. Conventional: 30 mg PO q6hr, increase every 1 or 2 days until angina controlled (usually 180-360 mg/day PO divided q6-8hr).

Verapamil. Immediate release 80 mg PO q8hr initially; usual range: 80-120 mg PO q8hr; not to exceed 480 mg/day. Extended release: 180 mg/day PO at bedtime initially; maintenance: 180-540 mg/day PO at bedtime.

Short-acting nitroglycerinsShort-acting nitroglycerins

Suitable for immediate relief of exertional or rest angina.

Can also be used for prophylaxis several minutes before planned exercise to avoid angina.

Nitroglycerin IV. Dosing and Uses: 5 mcg/min, increase by 5 mcg/min q 3-5min up to 20 mcg/min, then increase by 10 mcg/min, may later increase by 20 mcg/min.

LongLong -acting nitroglycerins-acting nitroglycerins

Isosorbide dinitrate. Initial: 10–20 mg po tid; can be increased to 40 mg tid.

Isosorbide dinitrate. Sustained-release capsules. Initial: 40 mg PO, maintenance: 40-80 mg PO q8-12hr.

Isosorbide mononitrate 20 mg po bid, with 7 h between 1st and 2nd doses.

Isosorbide mononitrate. Sustained-release capsules. 30 or 60 mg once/day, increased to 120 mg or, rarely, 240 mg.

Angiotensin-converting enzyme Angiotensin-converting enzyme inhibitorsinhibitors

ACE Inhibitors have been shown to reduce rates of death, MI, stroke, and need for revascularization procedures in patients with coronary artery disease or diabetes mellitus and at least one other cardiovascular risk factor, irrespective of the presence of hypertension or heart failure.

Ramipril. Reduction of Myocardial Infarction/Stroke Risk 2.5-10 mg PO qDay.

Antiplatelet drugs

Antiplatelet drugs inhibit platelet aggregation. 

Aspirin. Dosing and Uses: Unstable Angina Pectoris 75-325 mg/day PO.

Clopidogrel. Dosing and Uses: Unstable angina 300 mg initial loading dose, follow by 75 mg PO qDay in combination with aspirin 75-325 mg PO qDay.

Ticlopidine. Dosing and Uses: 250 mg po bid

Anti-ischemic agents, miscellaneous

Ranolazine. Cardioselective anti-ischemic agent (piperazine derivative) that partially inhibits fatty acid oxidation.

Used in combination with amlodipine, beta-blockers, or nitrates.

Treatment of Chronic Angina 500 mg PO BID initially; may increase dose based on clinical symptoms, not to exceed 1000 mg PO BID.

StatinsStatins Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin

Revascularization

Revascularization (eg, angioplasty, stenting) should be considered if angina persists despite drug therapy and worsens quality of life or if anatomic lesions (noted during angiography) put a patient at high risk of mortality.