Angina Pectoris

Aka: Angina Pectoris, Angina, Myocardial Ischemia, Ischemic Heart Disease, Vasospastic Angina, Prinzmetal's Angina

1. See Also
   1. Angina Diagnosis
   2. Unstable Angina
2. History
   1. Ask Exercise History
   2. How often do you take Nitroglycerin?
3. Symptoms
   1. See Chest Pain
4. Diagnosis
   1. See Angina Diagnosis
5. Types: Angina
   1. Chronic Angina (Fixed Obstruction)
      1. Resting Angina: 90% stenosis
      2. Pretreat higher endurance activities
         1. Take Nitroglycerin sublingual before activity
   2. Unstable Angina (Plaque rupture)
      1. Myocardial Infarction high risk
         1. Often occurs with 2 weeks of symptom onset
   3. Vasospastic Angina (Prinzmetal's Angina)
      1. Most arterial lesions are eccentric (75%)
         1. Considerable vasoactivity in most vessels
      2. Vasoconstriction occurs at lesion with Exercise
         1. Paradoxical: vasodilatation would be expected
         2. Occurs due to passive vasodilation down stream
         3. Prevention
            1. Beta-Blocker
            2. Calcium Channel Blocker (may act in similar way)
6. Labs: Biomarkers of chronic disease
   1. NT-proBNP
      1. Confers >5 fold risk of mortality if increased
   2. hs-CRP
      1. Confers up to 1.3 risk of coronary disease
   3. References
      1. Ndrepepna (2005) Circulation 112:2102-2107
7. Management: Non-Pharmacologic
   1. Mental Stress confers Myocardial Ischemia risk
      1. Decreases Left Ventricular Ejection Fraction
      2. Doubles the risk of ischemic complications
   2. References
      1. Jiang (1996) JAMA 275:1651-6
8. Management: Pharmacologic (Mechanisms of action)
   1. Protocol
      1. Pearls
         1. Stress test or angiography again if need >2 agents
      2. Options
         1. Sublingual Nitroglycerin prn and before Exercise
         2. Beta Blockers (preferred)
         3. Long acting nitroglcerin
         4. Calcium Channel Blocker (third-line)
   2. Nitroglycerin
      1. Effects
         1. Reduces Preload
         2. Reduces afterload
         3. Dilates collaterals
   3. Beta Blocker
      1. Reduces Heart Rate
      2. Reduces afterload
      3. Decreases cardiac contractility
      4. Contraindications
         1. Decompensated Congestive Heart Failure (CHF)
   4. Calcium Channel Blocker
      1. Reduces afterload
      2. Prevents Vasoconstriction
         1. No significant effect on vasodilatation
   5. Aspirin
      1. Platelet aggregation
   6. Combination: Beta Blocker with:
      1. Dihydropyridine Calcium Channel Blocker OR
      2. Nitroglycerin
   7. Ranolazine
      1. Used in combination with other agents above
      2. Reduces Angina frequency and Nitroglycerin use
      3. Chaitman (2004) JAMA 291:309-16
   8. Lipid lowering agents
      1. Decrease morbid events significantly
         1. Myocardial Infarction
         2. Angina
      2. Do not significantly affect coronary lesions size
      3. Do probably change composition of Plaques
         1. Decreases risk of Plaque rupture
9. Management: Comorbidity
   1. Major Depression
   2. Obstructive Sleep Apnea
   3. Obesity
   4. Cerebrovascular Disease symptoms
   5. Peripheral Vascular Disease
10. Management: Patient Instructions
    1. Rehearse what to do:
       1. Chest Pain
          1. Take one Nitroglycerin sublingually at onset
          2. Chew one Aspirin 162 to 325 mg (in whom there is no contraindication)
          3. Seek immediate medical attention if symptoms worsen or do not improve within 5 minutes
       2. Transient Ischemic Attacks
    2. Review Prevention
       1. See Cardiac Risk Reduction
       2. Omega-3-Fatty Acids
       3. Increase activity
    3. Testing (review if current, esp. if high risk)
       1. Stress Testing every 3-5 years
       2. Coronary Artery Disease Biomarkers (see above) every 3-5 years
       3. Secondary prevention labs
          1. Lipid profile
          2. Hemoglobin A1C
    4. Review Goals
       1. Blood Pressure <130/80
       2. LDL Cholesterol <70-100 mg/dl
       3. HDL Cholesterol >45 mg/dl
       4. Body Mass Index optimization
       5. Hemoglobin A1C < 7.0
    5. Review Medications
       1. Aspirin
       2. ACE Inhibitor
       3. Beta Blocker
       4. Antianginals
    6. Follow-up
       1. Primary care visits every 6 months if stable
       2. Cardiology every 1-2 years
    7. Handouts
       1. Updated medication list and after visit summary
       2. Mediterranean Diet
11. Documentation: Problem Summary
    1. History of Myocardial Infarction
    2. Ejection Fraction
    3. Revascularization procedures
    4. Angina (stability, severity, ischemic equivalents)
    5. Stress tests and imaging
    6. Secondary prevention goals at target?