angina pectoris-101111112

8/11/2019 angina pectoris-101111112

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This lecture was conducted during the Nephrology UnitGrand Ground by Medical Student rotated under Nephrology

Division under the supervision and administration of Prof.

Jamal Al Wakeel, Head of Nephrology Unit, Department of

Medicine and Dr. Abdulkareem Al Suwaida, Chairman of theDepartment of Medicine. Nephrology Division is not

responsible for the content of the presentation for it is

intended for learning and /or education purpose only.


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Definition of Angina Pectoris

is the result of myocardial ischemia caused by animbalance between myocardial blood supply andoxygen demand.

Angina is a common presenting symptom

(typically, chest pain) among patients withcoronary artery disease.

Angina pectoris is more often the presentingsymptom of coronary artery disease in women thanin men.

Increase with age

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Types of angina

1. Stable angina.

2. Unstable angina

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Stable angina

is that occurs when coronary perfusion isimpaired by fixed or stable atheroma of

coronary arteries.

Ex. Pt. has fixed capacity of exertion afterhe starts feeling chest pain.


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Unstable angina

is that characterized by rapidly worseningchest pain on minimal exertion or at rest.

= ulcerated atheroma+ thrombusformation>>> reduction of coronary blood

flow caused by thrombus>> angina at rest


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Unstable angina

Recent onset (less than 1 month).

Increase frequency and duration of episode.

Angina at rest not responding readily to

therapy. If the pain more than 30 min.????

MI


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Stable Angina Classification

Exertional

Variant or Prinzmetals Angina

Anginal Equivalent Syndrome

Syndrome-X Silent Ischemia

Decubitus angina

Noctural angina

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Exertional or classical

It occurs due to increase myocardial oxygendemand during exertion or emotion in a

patient of narrow coronary arteries. It

relieved by rest and nitroglycerine. Coronary artery obstructions are not

sufficient to result in resting myocardial

ischemia. However, when myocardial

demand increases, ischemia results.

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Variant or Prinzmetals Angina

Transient impairment of coronary bloodsupply by vasospasm or platelet aggregation

Majority of patients have an atherosclerotic

plaque Generalized arterial hypersensitivity

Long term prognosis very good

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Prinzmetals Angina

Spasm of a large coronary artery

Transmural ischemia

ST-Segment elevation at rest or with

exercise More prolonged than in classical angina.

It occurs more in women under age 50.

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Anginal Equivalent Syndrome

Patients with exertional dyspnea rather thanexertional chest pain

Caused by exercise induced left ventricular

dysfunction

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Silent Ischemia

Very common

More episodes of silent than painfulischemia in the same patient

Difficult to diagnose Holter monitor

Exercise testing

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Holter monitor

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Decubitus angina

Occurs when pt. lies down.

Usually ass. With impaired LV function.

Pt usually has severe CAD when pt, has

these symptoms,

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Noctural angina

It awakes the pt. from sleep,

It may provoked by vivid dreams.

It may occur due to CAO or coronary spasm

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The Canadian Cardiovascular Society

grading scale

is used for classification of angina severity, as follows:

Class I: Angina only during strenuous or prolonged physicalactivity

Class II: Slight limitation, with angina only during vigorousphysical activity Class III: Symptoms with everyday living activities, ie, moderate

limitation

Class IV: Inability to perform any activity without angina or

angina at rest, ie, severe limitation

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Causes:

Decrease in myocardial blood supply due to increasedcoronary resistance in large and small coronaryarteries:

1. Significant coronary atherosclerotic lesion in the large epicardialcoronary arteries (ie, conductive vessels) with at least a 50&percnt;

reduction in arterial diameter2. Coronary spasm (ie, Prinzmetal angina)3. Abnormal constriction or deficient endothelial-dependent relaxation

of resistant vessels associated with diffuse vascular disease (ie,microvascular angina)

4. Syndrome X

5. Systemic inflammatory or collagen vascular disease, such asscleroderma, systemic lupus erythematous, Kawasaki disease,polyarteritis nodosa, and Takayasu arteritis

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Cause cont.

Increased extravascular forces, such as severe LVhypertrophy caused by hypertension, aortic stenosis, orhypertrophic cardiomyopathy, or increased LV diastolicpressures

Reduction in the oxygen-carrying capacity of blood, such aselevated carboxyhemoglobin or severe anemia (hemoglobin


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Causes cont.

Structural abnormalities of the coronaryarteries

1. Congenital coronary artery aneurysm orfistula

2. Coronary artery ectasia

3. Coronary artery fibrosis after chest radiation

4. Coronary intimal fibrosis following cardiactransplantation

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Risk factors:

Major risk factors for atherosclerosis: like familyhistory of premature CAD, cigarette

smoking,DM,hypercholesterolemia(Metabolic

syndrome), or systemic HTN

Other risk factors: These include LV hypertrophy,obesity,

N.A.N 2009
http://emedicine.medscape.com/article/150916-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/150916-overview


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Precipitating factors:

These include factors such as severeanemia, fever, tachyarrhythmias,

catecholamines, emotional stress, and

hyperthyroidism, which increase

myocardial oxygen demand.

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Preventive factors:

Factors associated with reduced risk ofatherosclerosis are a high serum HDL

cholesterol level, physical activity,

estrogen, and moderate alcohol intake (1-

2 drinks/d).

???!! Plz Dont drink and smoke 4u life.

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Stable Angina

Evaluation of LV Function

Physical exam CXR

Echocardiogram

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Stable Angina

Evaluation of Ischemia

History Baseline Electrocardiogram

Exercise Testing

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CCSC Angina Classification

Class I

Class II

Class III

Class IV

Angina only withextreme exertion

Angina with walking

1 to 2 blocks

Angina with walking

1 block

Angina with minimal

activity

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ECG

ST segment depression with or without Twave inversion that reverse after ischemia

disappears.

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ECG

Elevation of ST segment in prinzmentalsangina.

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ECG

The resting ECG may be normal betweenattacks however it may show old MI, heart

block or LVH

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Stable Angina

Exercise Testing

The goal of exercise testing is to induce acontrolled, temporary ischemic state during

clinical and ECG observation

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Angina: Exercise Testing

High Risk Patients

Significant ST-segment depression at lowlevels of exercise and/or heart rate


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Angina: Exercise Testing

Low Risk Group

CASS Registry: 7 year survival

Less than 1 mm ST depression in Stage IIIof Bruce Protocol

Annual mortality: 1.3%

JACC 1986;8:741-8

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Exercise Testing

Contraindications

MIimpending or acute Unstable angina Acute myocarditis/pericarditis Acute systemic illness

Severe aortic stenosis Congestive heart failure Severe hypertension

Uncontrolled cardiac arrhythmias

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Stable Angina

Stress Echo

Ischemia may cause wall motion abnormalities, norise of fall in LVEF ( left ventricular ejection fraction)

This formula gives one a fraction, e.g., 0.60. Multiply this fraction by 100 gives a % figure, e.g., 60%

Sensitivity/specificity same as nuclear testing

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Cardiac Catheterization

Indications

Suspicion of multi-vessel CAD Determine if CABG/PTCA feasible

Rule out CAD in patients with

persistent/disabling chest pain andequivocal/normal noninvasive testing

percutaneous transluminal coronary angioplasty

coronary artery bypass grafting

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Angina: Treatment Goals

Feel better Live longer

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Stable Angina


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Stable Angina

Treatment Options

Medicine Percutaneous

Intervation

CABG

Angina

Treatment Options

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Stable Angina


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Stable Angina

Non-Invasive Evaluation

Coronary Arteriography

LV Dysfunction


High Risk

Medical Therapy

Stable


Recurrent Angina

Medical Therapy

Low Risk

Stress Testing

Normal LV Function

Resting LV Function

(Clinical Assessment)

Nondisabling Angina

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Stable Angina

Treatment Options

Medical Treatment

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bl i


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Stable Angina

Current Pharmacotherapy

Beta-blockers Calcium channel blockers

Nitrates

Aspirin Statins

? ACE inhibitors

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S bl A i


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Stable Angina

Considerations when Choosing a Drug

Effect on myocardium Effect on cardiac conduction system

Effect on coronary/systemic arteries

Effect on venous capitance system Circadian rhytm

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Reference

Medical diagnosed and mangement 8th2006 ,mohammedDanish OHCM 7th 250 cases in clinical examination. pocket clincal medicine 3nd. Kumar & Clark http://www.ncbi.nlm.nih.gov/ http://emedicine.medscape.com/article/150215-overview http://www.heartfailurematters.org http://health.allrefer.com/

Ect..

N.A.N 2009
http://www.ncbi.nlm.nih.gov/http://emedicine.medscape.com/article/150215-overviewhttp://www.heartfailurematters.org/http://health.allrefer.com/http://health.allrefer.com/http://www.heartfailurematters.org/http://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://www.ncbi.nlm.nih.gov/


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THANKS 4 HEARING MY

PRESENTATION

I hope that it is usefulMy best regards

NASRULLAH NASRULLAH (N A N)

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angina pectoris-101111112