Your SlideShare is downloading. ×
Chronic Stable Angina
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Chronic Stable Angina

2,828
views

Published on

This is a power point presentation titled "Chronic Stable Angina" . For more medical power points, PDFs, ECGs, X-rays, please visit www.medicaldump.com

This is a power point presentation titled "Chronic Stable Angina" . For more medical power points, PDFs, ECGs, X-rays, please visit www.medicaldump.com

Published in: Health & Medicine

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,828
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
148
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Figure 1. Typical Progression of Coronary Atherosclerosis. As the plaque burden increases, the atherosclerotic mass tends to stay external to the lumen, which allows the diameter of the lumen to be maintained; this is known as the Glagov effect, or positive remodeling.1 As plaque encroaches into the lumen, the coronary artery diameter decreases. Myocardial ischemia results from a discordant ratio of coronary blood supply to myocardial oxygen consumption. Luminal narrowing of more than 65 to 75 percent may result in transient ischemia and angina. In acute coronary syndromes, vulnerable plaque is a more important factor than is the degree of stenosis; acute coronary events result from ulceration or erosion of the fibrous cap, with subsequent intraluminal thrombosis. 2, 3 Vulnerable plaque within the vessel wall may not be obstructive and thus may remain clinically silent until it causes rupture and associated consequences. (The figure has been modified from Greenland et al., 4 with permission.)‏
  • Figure 2. Kaplan-Meier Survival Curves. In Panel A, the estimated 4.6-year rate of the composite primary outcome of death from any cause and nonfatal myocardial infarction was 19.0% in the PCI group and 18.5% in the medical-therapy group. In Panel B, the estimated 4.6-year rate of death from any cause was 7.6% in the PCI group and 8.3% in the medical-therapy group. In Panel C, the estimated 4.6-year rate of hospitalization for acute coronary syndrome (ACS) was 12.4% in the PCI group and 11.8% in the medical-therapy group. In Panel D, the estimated 4.6-year rate of acute myocardial infarction was 13.2% in the PCI group and 12.3% in the medical-therapy group.
  • Transcript

    • 1. CHRONIC STABLE ANGINA
    • 2. A 47-year-old man reports a six-month history of intermittent chest discomfort while playing squash. He describes lower substernal tightness with numbness of the left upper arm only during exertion. He does not smoke. His father died suddenly at the age of 49 years. His blood pressure is 138/84 mm Hg. The level of total cholesterol is 261 mg per deciliter (6.7 mmol per liter), of low-density lipoprotein cholesterol 172 mg per deciliter (4.4 mmol per liter), and of high-density lipoprotein cholesterol 50 mg per deciliter (1.3 mmol per liter), and the triglyceride level is 113 mg per deciliter (2.9 mmol per liter). The result of an exercise test is positive, with pain and 1.5 mm of horizontal ST-segment depression at stage 4 of the Bruce protocol. How should the patient's case be managed? Abrams,NEJM,2005;352:2524-2533 Case history
    • 3. Chronic Stable Angina
      • Pathophysiology
      • Diagnosis
      • Management
        • Lifestyle modification
        • Antianginal therapy
          • Medication
          • Invasive
          • Other
        • Vasculoprotective therapy
    • 4. Typical Progression of Coronary Atherosclerosis. Abrams,NEJM,2005;352:2524-2533
    • 5. Symptoms of Angina. Abrams J. N Engl J Med 2005;352:2524-2533.
    • 6. Classification and Severity of Angina. Abrams J. N Engl J Med 2005;352:2524-2533. Abrams,NEJM,2005;352:2524-2533
    • 7. Common Stress-Testing Procedures for the Evaluation of Chest Pain. Abrams J. N Engl J Med 2005;352:2524-2533.
    • 8.
      • Lifestyle Modification
        • Regular aerobic activity
        • Diet
        • Tobacco abstinence and avoidance of passive smoke
        • Logistics
      • Optimize non cardiac comorbidities
      Non Pharmacologic Therapy
    • 9. Recommended Antianginal Drugs. Abrams J. N Engl J Med 2005;352:2524-2533.
    • 10. The Vasculoprotective Regimen for Stable Angina. Abrams J. N Engl J Med 2005;352:2524-2533.
    • 11. Boden WE, ORourke, RA, Teo KK, Hartigan P, Maron D, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med 2007;356:1503-16.
    • 12. Study Overview
      • In a randomized trial, 2287 patients with coronary artery disease and evidence of ischemia were assigned to receive optimal medical therapy with or without percutaneous coronary intervention (PCI)
      • At a median of 4.6 years, the rates of death and myocardial infarction were 19.0% in the PCI group and 18.5% in the medical-therapy group
      • The PCI group had lower rates of angina and repeat revascularization
      Boden,NEJM,2007;356:1503-1516
    • 13. Kaplan-Meier Survival Curves Boden WE et al. N Engl J Med 2007;356:1503-1516 Boden,NEJM,2007;356:1503-1516
    • 14. Courage Trial
      • As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy
      Boden,NEJM,2007;356:1503-1516
    • 15. Conclusions
      • Diagnosis of chronic stable angina is made on the basis of stable anginal symptoms, non-invasive stress testing indicating ischemia, and as appropriate coronary angiography.
      • Antianginal drugs should be prescribed to relieve symptoms. Beta blockers should be used unless contraindicated or not tolerated.
    • 16.
      • Lifestyle modification and management of non-cardiac comorbidities is important.
      • It needs to be understood that coronary artery disease is a chronic condition, which is manageable but not curable.
    • 17.
      • Vasculoprotective therapy is important including antiplatelet agents such as aspirin and clopidogrel, statins, and ACEI
      • Under most circumstances, optimal medical therapy is primary approach and revascularization should be considered as needed or for special coronary anatomy.
    • 18. Chronic Stable Angina References 1. Abrams J. Chronic Stable Angina. N Engl J Med 2005;352:2524-33. 2 . Fraker TD Jr, Fihn SD. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guideline for the Management of Patients with Chronic Stable Angina . J. Am. Coll. Cardiol . 2007;50:2264-2274. 3. Boden WE, ORourke, RA, Teo KK, Hartigan P, Maron D, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease . N Engl J Med 2007;356:1503-16. 4. Hochman JS, Steg PG. Does Preventive PCI Work? N Engl J Med 2007;356:1572-1574. 5. Peterson ED, Rumsfeld JS. Finding the Courage to Reconsider Medical Therapy for Stable Angina . N Engl J Med 2008;359:7:751-753. 6. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, et al. Coronary Intervention for Persistent Occlusion after Myocardial Infarction. N Engl J Med 2006;355:2395-407. 7. Mark DB, Pan W, Clapp-Channing NE, Anstrom KJ, et al. Quality of Life after Late Invasive Therapy for Occluded Arteries. N Engl J Med 2009;360:774-83.
    • 19. Quiz-Question 1
      • What is best initial screening test for patient with stable exertional angina, arthritis, hypertension, and LBBB?
          • Treadmill stress echo
          • Dobutamine stress echo
          • Lexiscan stress myocardial scan
          • Dobutamine stress myocardial scan
          • Treadmill stress myocardial scan.
    • 20. Quiz-Question 2
      • What is best test for a patient with known stable angina who awakens from sleep with anginal type chest pain for the first time?
          • Treadmill exercise test.
          • Lexiscan stress myocardial scan
          • Dobutamine stress echo
          • Cardiac catheterization
    • 21. Quiz-Question 3
      • When added to optimal medical therapy for chronic stable angina, PCI prolongs life and reduces chance of myocardial infarction
          • True
          • False
    • 22. Quiz-Question 4
      • Which drug is vasculoprotective?
          • Isosorbide dinitrate
          • Amlodipine
          • Atorvastatin
          • Diltiazem