Definition Types of Angina Management of Angina Antianginal drugs MAIN
EXIT
NEXT
Myocardial Blood Flow Myocardial O2 Demands
Transient Myocardial ischemia
Severe Chest pain
Angina Pectoris 2 BACK
MAIN
EXIT
INDEX
NEXT
Chest pain caused by transient myocardial ischemia due to an imbalance between myocardial oxygen supply and demand.
It is manifested as a heavy, compressing or crushing retrosternal pain or discomfort radiating to the left shoulder, flexor aspect of the left arm, jaw or epigastrium. 3 BACK
MAIN
EXIT
INDEX
NEXT
Pulmonary embolism A lung infection Aortic dissection Aortic stenosis Hypertrophic cardiomyopathy Pericarditis 4 BACK
MAIN
EXIT
INDEX
NEXT
Types of Angina 1. Stable Angina (classical, typical). 2. Unstable Angina. 3. Variant Angina. 4. Microvascular Angina. 5 BACK
MAIN
EXIT
INDEX
NEXT
Other Names for Angina • • • • • • • • •
Angina pectoris Acute coronary syndrome Chest pain Acute coronary disease Coronary artery spasms Prinzmetal's angina Stable or common angina Unstable angina Variant angina
Types of Angina • Chronic stable angina (also called classic or effort angina)
• Unstable angina (also called preinfarction or crescendo angina)
• Vasospastic angina (also called Prinzmetal’s or variant angina)
4 types 1.Stable
Types of Angina
most common has common pattern occurs during exercise decreases at rest treatable
2.Unstable no pattern not relieved by rest/medicine preclude to heart attack
3.Variant (or Prinzmetal’s) rare occurs at rest between midnight and early morning Relieved by medicine 4- microvascular More severe and last longer than other type of angina Medicine may not relive this type of angina
Stable Angina Symptoms • Occurs when the heart must work harder, usually during physical exertion • Doesn't come as a surprise, and episodes of pain tend to be alike • Usually lasts a short time (5 minutes or less) • Is relieved by rest or medicine • May feel like gas or indigestion • May feel like chest pain that spreads to the arms, back, or other areas
Unstable Angina Symptoms • Often occurs at rest, while sleeping at night, or with little physical exertion • Comes as a surprise • Is more severe and lasts longer (as long as 30 minutes) than episodes of stable angina • Is usually not relieved with rest or medicine • May get continually worse • May mean that a heart attack will happen soon
Variant Angina Symptoms • Usually occurs at rest and during the night or early morning hours • Tends to be severe • Is relieved by medicine
1. Stable Angina (classical, typical). The commonest cause is ADVANCED ATHEROSCELEROSIS
,have episodes of chest discomfort that are usually predictable such as on exertion or under stress
Retrosternal pain Radiating to left arm & shoulder Lasting less than 15 min. 12 BACK
MAIN
EXIT
INDEX
NEXT
Stable Angina Predisposing factors
Emotion
Heavy meals
Relieving factors
Exertion
Exposure to cold weather
Rest sublingual nitroglycerin, Beta blockers 13 BACK
MAIN
EXIT
INDEX
NEXT
2. Unstable Angina . the chest pain is unexpected and usually occurs while at rest. The discomfort may be more severe and prolonged than typical angina N.B. Pain occurs with less exertion or at rest Myocardial infarction may occur in 10-20% of patients. 14 BACK
MAIN
EXIT
INDEX
NEXT
3. Variant
Angina . (Prinzmetal) Chest pain at rest due to coronary artery spasm
15 BACK
MAIN
EXIT
INDEX
NEXT
The list of risk factors mentioned for :-Angina in various sources includes Smoking - 1 Obesity - 2
High saturated fat diet - 3 High salt diet - 4
Hypertension - 5
Atherosclerosis - 6
Diabetes - 7
Inactivity - 8 Stress - 9
Management of Angina Management of Stable Angina Management of Unstable Angina Management of Variant Angina 17 BACK
MAIN
EXIT
INDEX
NEXT
Management of Stable Angina 1- General measures. 2- Drug Treatment. 3- Coronary artery revascularization. 18 BACK
MAIN
EXIT
INDEX
NEXT
General measures Treat Hypertension , Hypercholestrolimia and Diabetes Stop smoking
AVOID Severe exertion
Reduce weight
Heavy meal
Emotions
•Graduated exercise may open new collaterals
Cold Weather
19 BACK
MAIN
EXIT
INDEX
NEXT
20 BACK
MAIN
EXIT
INDEX
NEXT
Treatment of an acute attack of angina Sublingual nitroglycerin or isosorbide dinitrate or Oral spray nitroglycerin, isosorbide dinitrate Persistence of pain
Relief within 1-3 min.
Repeat nitroglycerin at 5 min. interval (3 tab. max.)
Relief
not relieved
Infarction
HOSPITALIZATION
21 BACK
MAIN
EXIT
INDEX
NEXT
Management of Unstable Angina Nitrate + Aspirin (low dose) and/or Heparin or Thrombolytic (stryptokinase) to minimize risk of infarction
22 BACK
MAIN
EXIT
INDEX
NEXT
Management of Variant Angina Nitrates and/or Ca++ Channel blockers For the acute attack & prophylaxis 23 BACK
MAIN
EXIT
INDEX
NEXT
What are the antianginal drugs? Organic nitrates. β- adrenoceptor blockers. Calcium channel blockers.
24 BACK
MAIN
EXIT
INDEX
NEXT
NITRATES Veins
Relaxation of smooth muscles Dilatation
Arteries 25 BACK
MAIN
EXIT
INDEX
NEXT
Cellular Mechanism of Vasodilatation Nitrates
Synthesis of cyclic GMP
Formation of Nitric oxide (NO) Activation of Guanylate cyclase
Relaxation of Vascular smooth muscles
N.B. (-SH) groups are required for formation of NO.
27
Adverse Reactions : 1- Postural Hypotension orthostatic hypotension & Syncope
2- Tachycardia
3- Drug Rash
4- Facial Flushing
5- Throbbing Headache
6- Prolonged high dose Methaemoglobinaemia 28 BACK
MAIN
EXIT
INDEX
NEXT
The main limitation of chronic nitrate therapy is TOLERANCE Tolerance to the antianginal effect occurs as a result of chronic administration How does it occur? It develops as SH groups in vessel wall become oxidized by constant exposure to nitrates, this prevents the production of NO & hence stimulation of Guanylate cyclase which is believed to be fundamental to smooth muscle relaxation produced by the drugs. “NITRATE FREE INTERVAL� of 8-10 hrs reduces or prevents development of nitrate tolerance.e.g. isosorbide dinitrate is given at 7am, noon and 5pm; trnsdermal patches should be used for about 12 hrs daily 29
β-blockers are effective in STABLE angina
In contrast they are not useful for vasospastic angina (Variant) {Prinzmetal} &
may worsen the condition. This deleterious effect is likely due to an increase in coronary resistance caused by the unopposed effects of catecholamines acting at Îą-adrenoceptors.
Mechanism of antianginal action: The effectiveness of β -adrenoceptor blockers in the treatment of exertional angina is attributable to a fall in myocardial O2 requirement at rest & during exertion due to : 1- A -ve chronotropic effect (particularly during exercise). 2- A -ve inotropic effect. 3- A reduction in arterial blood pressure (particularly systolic pressure) during exercise.
31 BACK
MAIN
EXIT
INDEX
NEXT
Adverse Reactions :
CHF
Cold extremities
A-V block
Worsening symptoms of PVD
Bronchospasm
Hypotension 32 BACK
MAIN
EXIT
INDEX
NEXT
Contraindications :
CHF
Peripheral Vascular disease
A-V block
Bronchial asthma
Hypotension 33 BACK
MAIN
EXIT
INDEX
NEXT
Used in treatment of all types of angina.
Verapamil Diltiazem
Dihydropyridine group Nifedipine Amlodipine 34 BACK
MAIN
EXIT
INDEX
NEXT
Mechanism of anti-anginal action : 1 - Coronary artery dilatation and relief of coronary spasm (variant angina) 2 -Decrease myocardial O2 demand due to: •Arteriolar dilatation
Vascular resistance
•(Verapamil & Diltiazem) •Decrease HR. •Decrease contractility •Decrease AV conductivity
Afterload
Adverse reactions :
Dizziness
Flushing
Ankle edema
Headache
Constipation A-V block & HF only with Verapamil & Diltiazem
Hypotension
Reflex Tachycardia with Nifedipine