Management of Stable Angina Pectoris

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Management ofStable Angina Pectoris

• David Putnam, MD
• Albany Medical College

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Angina Pectoris

• Classic angina is characterized by substernal
  squeezing chest pain, occurring with stress and
  relieved with rest or nitroglycerin.
• May radiate down the left arm
• May be associated with nausea, vomiting, or
  diaphoresis.

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Angina
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Stable AnginaClassification

• Exertional
• Variant
• Anginal Equivalent Syndrome
• Prinzmetals Angina
• Syndrome-X
• Silent Ischemia

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Angina Exertional

• Coronary artery obstructions are not sufficient
  to result in resting myocardial ischemia.
  However, when myocardial demand increases,
  ischemia results.

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Angina Variant Angina

• Transient impairment of coronary blood supply by
  vasospasm or platelet aggregation
• Majority of patients have an atherosclerotic
  plaque
• Generalized arterial hypersensitivity
• Long term prognosis very good

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Angina Anginal Equivalent Syndrome

• Patients with exertional dyspnea rather than
  exertional chest pain
• Caused by exercise induced left ventricular
  dysfunction

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Angina Prinzmetals Angina

• Spasm of a large coronary artery
• Transmural ischemia
• ST-Segment elevation at rest or with exercise
• Not very common

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Angina Syndrome X

• Typical, exertional angina with positive exercise
  stress test
• Anatomically normal coronary arteries
• Reduced capacity of vasodilation in
  microvasculature
• Long term prognosis very good
• Calcium channel blockers and beta blockers
  effective

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Angina Silent Ischemia

• Very common
• More episodes of silent than painful ischemia in
  the same patient
• Difficult to diagnose
• Holter monitor
• Exercise testing

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Angina Treatment Goals

• Feel better
• Live longer

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Angina Prognosis

• Left ventricular function
• Number of coronary arteries with significant
  stenosis
• Extent of jeoporized myocardium

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Stable Angina

• Risk stratification
• Noninvasive testing
• Cardiac catheterization

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Stable AnginaEvaluation of LV Function

• Physical exam
• CXR
• Echocardiogram

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Stable AnginaEvaluation of Ischemia

• History
• Baseline Electrocardiogram
• Exercise Testing

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CCSC Angina Classification

• 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

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Stable AnginaExercise Testing

• The goal of exercise testing is to induce a
  controlled, temporary ischemic state during
  clinical and ECG observation

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Angina Exercise Testing
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Angina Exercise TestingHigh Risk Patients

• Significant ST-segment depression at low levels
  of exercise and/or heart rate
• Fall in systolic blood pressure
• Diminished exercise capacity
• Complex ventricular ectopy at low level of
  exercise

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Angina Exercise TestingLow Risk Group

• CASS Registry 7 year survival
• Less than 1 mm ST depression in Stage III of
  Bruce Protocol
• Annual mortality 1.3
• JACC 19868741-8

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ECG Treadmill EST in Women

• Higher false-positive rate
• Reduces procedures without loss of diagnostic
  accuracy
• Only 30 of women need be referred for further
  testing

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Stable AnginaGuidelines for Nuclear EST

• Diagnosis/prognosis for CAD
• Non-diagnostic EST
• Abnormal resting ECG
• Negative EST with continued chest pain
• Intermediate probability of disease

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Stable AnginaGuidelines for Nuclear EST

• Defined CAD
• Post infarct risk stratification
• Risk stratification to determine need for
• revascularization ( viability study )

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Stable AnginaDipyridamole Nuclear EST

• Near equivalent sensitivity/specificity with
  symptom-limited nuclear EST
• Most useful in patients who cannot exercise
• Major contraindication is severe bronchospastic
  lung disease ( consider Dobutamine study )

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Appropriateness of Radionuclide Exercise Testing

• Retrospective analysis of 1092 patients
• 64 of tests ordered by cardiologists were
  indicated
• 30 of tests ordered by non-cardiologists were
  indicated
• Excessive charges from non-indicates tests were
  1,082,400
• Am J Card 199677139-42

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Stable AnginaStress Echo

• Ischemia may cause wall motion abnormalities, no
  rise of fall in LVEF
• Sensitivity/specificity same as nuclear testing
• May be better in women

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Stress Echo vs. Nuclear Stress
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Exercise TestingContraindications

• 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 AnginaNon-Invasive Evaluation
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Cardiac CatheterizationIndications

• Suspicion of multi-vessel CAD
• Determine if CABG/PTCA feasible
• Rule out CAD in patients with persistent/disabling
  chest pain and equivocal/normal noninvasive
  testing

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Risk Factor Modification

• Hypertension
• Smoking
• Dyslipidemia
• Diabetes Mellitus
• Obesity
• Stress
• Homocysteine

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Stable AnginaTreatment Options
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Stable AnginaTreatment Options

• Medical Treatment

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Stable AnginaCurrent Pharmacotherapy

• Beta-blockers
• Calcium channel blockers
• Nitrates
• Aspirin
• Statins
• ? ACE inhibitors

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Stable AnginaConsiderations 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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Beta-Blockers

• 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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Beta-Blockers
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Beta BlockersSide Effects

• Bronchospasm
• Diminished exercise capacity
• Negative inotropy
• Sexual dysfunction
• Bradyarrhythmia
• Masking of hypoglycemia
• Increased claudication
• Hair loss

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Beta BlockersCommon Available Agents

• Propranolol
• Atenolol
• Metoprolol
• Nadolol
• Timolol

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Calcium Channel BlockersMechanisms of Action

• 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

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Calcium Channel BlockersMechanisms of Action
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Calcium Channel BlockersMechanisms of Action
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Calcium Channel BlockersSide Effects

• Palpitations
• Headache
• Ankle edema
• Gingival hyperplasia

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Calcium Channel BlockersAvailable Agents

• Verapamil
• Diltiazem
• Nifedipine
• Nicardipine
• Amlodipine
• Felodipine
• Nisoldipine
• Bepridil

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Stable AnginaTreatment Options
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NitratesMechanisms of Action

• Nitric oxide has been identified as
  endothelium-derived relaxing factor
• Organic nitrates are therapeutic precursors of
  endothelium-derived relaxing factor

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NitratesMechanisms of Action

• 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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NitratesReducing Tolerance

• 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

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NitratesSide Effects

• Headache
• Flushing
• Palpitations
• Tolerance

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• To provide optimal benefit to patients,
  clinicians must use nitroglycerin more
  systematically and critically than they have
  before
• W. Frischman

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NitratesCommon Available Agents

• Isorbide dinitrate
• Isorbide mononitrate
• Long-acting transdermal patches
• Nitroglycerin sl

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Stable AnginaTreatment Options

• CABG

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Stable AnginaResults of CABG

• 65 remain symptom-free at ten years
• 85 remain free of fatal/nonfatal MI at ten years
• Mortality of 2-3 yearly over ten years
• 2.5 incidence of perioperative MI

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CABG vs. Medical Rx

• Three major randomized trials
• A. VACS
• B. ECSS
• C. CASS
• Improved mortality in CABG group
• A. L-main CAD
• B. 3-vessel CAD, esp. with decreased EF
• C. LAD disease, severe angina, decreased EF

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Stable Angina CABG

• Nevertheless, bypass grafting remains a
  palliative procedure, as is every known treatment
  for coronary disease, and it assure permanent
  freedom neither from symptoms nor from a fatal
  coronary event
• Hull R. Tex Hrt Jnl 198916127-129

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Stable AnginaTreatment Options

• PTCA

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PTCA vs. Medical Management

• Review of six major trials
• Greater symptomatic benefit in PTCA group
• No change in mortality or rates of MI
• Higher rate of CABG in PTCA group
• BMJ 2000(Jul)32173-77.

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PTCA vs Medical ManagementMultivessel Disease
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Stable AnginaResults of PTCA

• 80 or greater success rate
• 1 mortality
• 3-5 emergency CABG ( prior to stenting )
• 4 acute MI

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CABG vs PTCAMultivessel Disease

• Review of six major randomized trials
• Most patients had preserved LVEF
• No differences in mortality or combined endpoint
  of death and nonfatal MI
• Second revascularization procedure more likely in
  first year after PTCA
• Surgery patients more likely to be angina free at
  one year

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CABG vs. PTCAMultivessel Disease

• Most patients had 2-vessel CAD, preserved LVEF,
  and suitable anatomy

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CABG vs. PTCA

• BARI Trial Subset of Diabetic Patients
• A. Five-year survival better in CABG group
• B. Increased incidence of MI at eight years
• C. More women, hypertension, CHF, and severe
  concomitant noncardiac disease
• D. More multi-vessel disease, significant
  lesions, and distal lesions

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Stable Angina 1-Vessel CADTherapeutic
Strategies

• Initiate pharmacologic treatment
• A. Nearly half of patients will become
  asymptomatic
• PTCA preferred alternative if medical therapy
  does not relieve angina or causes adverse effects

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Stable Angina 2-Vessel CADTherapeutic
Strategies

• Initial medical management in patients with mild
  ischemic symptoms and normal LV function
• Revascularization in patients who fail medical
  therapy
• Selection of PTCA vs. CABG depends on coronary
  anatomy, LV function, need for complete
  revascularization, and patient preference

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Stable Angina 3-Vessel CADTherapeutic
Strategies

• CABG in patients with left-main disease or
  3-vessel CAD and decreased LVEF
• PTCA or medical management an alternative in
  patients with 3-vessel CAD, mild symptoms, and
  preserved LVEF

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Chronic Angia Reading List

• Gersh BJ, Solomon AJ. Management of chronic
  stable angina medical therapy, PTCA, and CABG.
  Ann Internal Med 1998(FEB)128216-223.

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