CAD

Angina Pectoris

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Angina Pectoris, Angina, Myocardial Ischemia, Ischemic Heart Disease

  • History
  1. Ask Exercise History
  2. How often do you take Nitroglycerin?
  • Symptoms
  • Diagnosis
  • 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. See Vasospastic Angina
  • 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 [PubMed]
  • 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 [PubMed]
  • Management
  • Pharmacologic (Mechanisms of action)
  1. Nitroglycerin
    1. Reduces Preload, reduces Afterload, dilates collaterals
  2. Beta Blocker
    1. Reduces Heart Rate, reduces Afterload, decreases cardiac contractility
    2. Contraindications
      1. Decompensated Congestive Heart Failure (CHF)
      2. Do not combine with Calcium Channel Blockers
  3. Calcium Channel Blocker
    1. Reduces Afterload, prevents Vasoconstriction (no significant effect on vasodilatation)
  4. Aspirin
    1. Decreases platelet aggregation
  • Management
  • Protocol
  1. Step 1
    1. Aspirin 81 mg daily
    2. Sublingual Nitroglycerin prn and before Exercise
    3. Beta Blocker (e.g. Metoprolol)
  2. Step 2
    1. Increase Beta Blocker dose OR
    2. Consider Isosorbide monohydrate XR (once daily, least expensive long acting nitrate)
  3. Step 3
    1. Consider adding Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine)
    2. Consider Stress test or angiography again if need >2 agents
  • Management
  • Other measures
  1. Ranolazine (Ranexa)
    1. Not more effective than other anti-Anginal medications
    2. Risk of QT Prolongation, multiple drug interactions and high expense (>$500/month)
    3. Used in combination with other agents above
    4. Reduces Angina frequency (by one less episode/week)
    5. Chaitman (2004) JAMA 291:309-16 [PubMed]
  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
      4. Continue to take Nitroglycerin every 5 minutes up to a total of 3 doses as needed for Chest Pain
    2. Transient Ischemic Attacks or Cerebrovascular Accident
      1. Immediate emergency department evaluation
  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
  • 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?