Stable angina and treatment

2. (Cardiology_59 ❤#ischemic_heart_disease_1( IHD#
‫ال‬ ‫وﺑﻴﻦ‬ Blood supply of heart ‫ال‬ ‫ﺑﻴﻦ‬ Imbalance ‫ﻓ‬ ‫ﺻﺎر‬ ‫ﻮن‬‫ﺑﻴ‬ Cardiac tissue ‫ﺑﺎل‬ Ischemia ‫ﻳﺼﻴﺮ‬ ‫ﻋﺸﺎن‬
Heart Demand
Decreased in Cardiac Blood Supply
Supply ‫ال‬ ‫ﻓ‬ ‫⬇ﻓﺎﻟﺨﻠﻞ‬ ‫اﻟﻤﻄﻠﻮب‬ ‫ﻣﻦ‬ ‫أﻗﻞ‬ ‫دم‬ ‫واﺻﻠﻪ‬ ‫اﻟﻘﻠﺐ‬
Increas in Cardiac tissue Demand
..‫زادت‬ ‫اﻟﻘﻠﺐ‬ ‫اﺣﺘﻴﺎﺟﺎت‬ ‫ﻦ‬‫ﻟ‬ ‫ﻛﺎﻓﻴﻪ‬ ‫ﻤﻴﺔ‬‫ﺑ‬ ‫دم‬ ‫واﺻﻠﻪ‬ ‫اﻟﻘﻠﺐ‬ ‫ﻫﻨﺎ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Cardiac blood Supply ‫ال‬ ‫ﺗﻘﻠﻞ‬ ‫ﻦ‬‫ﻣﻤ‬ ‫اﻟﻠ‬ ‫اﻷﺳﺒﺎب‬ ‫ﻫ‬ ‫ﺷﻮ‬
... Low Cardiac output
‫ال‬ ‫او‬ Heart Failure ‫ال‬ ‫ﺣﺎﻻت‬ ‫زي‬ ‫اﻟﻤﻄﻠﻮب‬ ‫ﻣﻦ‬ ‫أﻗﻞ‬ ‫وﻳﻮﺻﻠﻪ‬ ‫ﻫﺘﺘﺄﺛﺮ‬ CO ‫ال‬ ‫ﻣﻦ‬ ‫اﻟﻘﻠﺐ‬ ‫ﻓﺤﺼﺔ‬ ‫ﻗﻠﻴﻞ‬ CO ‫ﺑﻴﻄﻠﻊ‬ ‫اﻟﻘﻠﺐ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬
Aortic stenosis ‫ال‬ ‫او‬ Pulmonary embolism
( Coronary Artery Disease ( CAD
‫ﻟﻠﻘﻠﺐ‬ blood supply ‫ال‬ ‫ﻋﻦ‬ ‫اﻟﻤﺴﺌﻮل‬ ‫ﻫﻮ‬ ‫ﺑﺄﻓﺮﻋﻪ‬ Coronary Aretry ‫ال‬
‫ﻟﻠﻘﻠﺐ‬ ‫اﻟﻮاﺻﻠﺔ‬ ‫اﻟﺪم‬ ‫ﻛﻤﻴﺔ‬ ‫ﻋﻠ‬ ‫ﺗﺄﺛﺮ‬ ‫رح‬ Coronary ‫ال‬ ‫ﻓ‬ ‫ﻠﻪ‬‫ﻣﺸ‬ ‫ﻓﺄي‬
.. ‫ﺣﺎﺟﺎت‬ 4 ‫ل‬ ‫ﺑﻨﻘﺴﻤﻬﺎ‬ Coronoray ‫ال‬ ‫ﻣﺸﺎﻛﻞ‬
Coronary ‫ال‬ ‫ﻓﺘﺤﺔ‬ ‫ﻓ‬ ‫ﻠﻪ‬‫اﻟﻤﺸ‬ ‫ﻛﺎﻧﺖ‬ ‫ﻟﻮ‬ 1⃣
Coronary artery ‫ال‬ ‫ﻓﺘﺤﺔ‬ ‫ﻓ‬ ‫ﺿﻴﻖ‬ congenital osteal stenosis ‫ﻋﻨﺪﻫﺎ‬ ‫ﻮن‬‫ﺑﻴ‬ ‫ﺣﺎﻻت‬ ‫ﻓ‬
Coronary ‫ال‬ ‫ﻓﺘﺤﻪ‬ ‫ﺑﻴﻀﻴﻖ‬ tertiary syphilis ‫ﺣﺎﻻت‬ ‫ﻓ‬ ‫او‬
syphilitic osteal stenosis
Coronary lumen ‫ال‬ ‫ﻓ‬ ‫ﻠﻪ‬‫اﻟﻤﺸ‬ ‫ﻛﺎﻧﺖ‬ ‫ﻟﻮ‬ 2⃣
Blood flow ‫ال‬ ‫وﺑﻴﻌﻴﻖ‬ Lumen ‫ال‬ ‫ﺑﻴﻀﻴﻖ‬ thrombosis Or embolism ‫ﺻﺎر‬ ‫ﻟﻮ‬
Coronary ‫ﻟﻞ‬ Emboli ‫ﻳﺒﻌﺖ‬ ‫ﻦ‬‫ﻣﻤ‬ AF ‫ﻣﺮﻳﺾ‬ ‫ﻣﺜﻼ‬
‫ال‬ ‫ﺣﺎﻻت‬ ‫زي‬ Hyper coaguable state ‫ﻣﺮﻳﺾ‬ ‫او‬
anti phospholipid syndrome
Protein C and S deficiency
Sickle cell anaemia in young age

3. Thrombosis ‫ﻟﻞ‬ ‫ﻋﺮﺿﺔ‬ ‫ﻮﻧﻮ‬‫ﺑﻴ‬
coronary endothelium ‫ال‬ ‫ﻓ‬ ‫ﻠﺔ‬‫اﻟﻤﺸ‬ ‫ﻛﺎﻧﺖ‬ ‫ﻟﻮ‬ 3⃣
‫ﺣﺎﻻت‬ ‫زي‬
vasculitis ‫او‬ Atherosclerosis ‫ال‬
IHD ‫ال‬ ‫اﺳﺒﺎب‬ ‫ﻣﻦ‬ %90 ‫ﻞ‬‫ﺑﺘﺸ‬ Atherosclerosis ‫ال‬ ‫⭐ﺣﺎﻻت‬
Coronary wall ‫ال‬ ‫ﻓ‬ ‫ﻠﺔ‬‫اﻟﻤﺸ‬ ‫ﻛﺎﻧﺖ‬ ‫ﻟﻮ‬ 4⃣
Corobary wall spasm Or dissecting aortic aneurysm
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
: ‫ﻫ‬ Cardiac Demand ‫ال‬ ‫ﺑﺘﺰود‬ ‫اﻟﻠ‬ ‫اﻷﺳﺒﺎب‬ ‫اﻣﺎ‬
thyrotoxicosis
cardiac hypertrophy as in HTN ,Aortic stenosis
Hypertrophic cardimyopathy
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

4. Cardiology_60❤#Ischemic_heart_disease2#
: ‫ﻛﺒﺎر‬ ‫ﻟﻨﻮﻋﻴﻦ‬ ‫ﺑﻨﻘﺴﻤﻪ‬ (Ischemic heart disease (IHD ‫ال‬
Acute Coronary Syndrome (ACS)
( Chronic Coronary Syndrome (CCS
: ‫ﺣﺎﻻت‬ ‫ﺗﻼت‬ ‫ﺑﻴﺸﻤﻞ‬ ACS ‫⭐ال‬
Unstable Angina 1⃣
2⃣STEMI ( ST elevated Myocardial Infarction )
(3⃣NSTEMI ( Non ST elevated Myocardial Infarction
.... ‫ﻣﺎت‬ ‫اﻟﻘﻠﺐ‬ ‫ﻋﻀﻠﺔ‬ ‫ﻣﻦ‬ ‫ﺟﺰء‬ ‫ﻓ‬ ‫ﻮن‬‫ﺑﻴ‬ Cell necrosis ‫ﻓﻴﻬﻢ‬ ‫ﺻﺎر‬ ‫ﻮن‬‫ﺑﻴ‬ NSTEMI ‫وال‬ STEMI ‫ال‬
: ‫ﺣﺎﻻت‬ 6 ‫ﺑﻴﺸﻤﻞ‬ CCS ‫ال‬ ⭐
1⃣Patients with suspected CAD and 'stable' anginal symptoms and/or dyspnoea
2⃣Patients with new onset of HF or LV dysfunction and suspected CAD
3⃣Asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS or
patients with recent revascularization
4⃣Asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization
5⃣Patients with angina and suspected vasospastic or microvascular disease
..6⃣Asymptomatic subjects in whom CAD is detected at screening
.. ‫ﻹﻟﻪ‬ Management ‫ال‬ ‫ﻣﻊ‬ ‫ﻧﻮع‬ ‫ﻛﻞ‬ ‫ﺑﺘﻔﺼﻴﻞ‬ ‫اﻟﻘﺎدﻣﺔ‬ ‫اﻟﺒﻮﺳﺘﺎت‬ ‫ﻓ‬ ‫ﻪ‬‫اﻟ‬ ‫ﺷﺎء‬ ‫ان‬ ‫ﻫﻨﺒﺪأ‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

6. (Cardiology_61❤#Ischemic_heart_disease_3( IHD#
‫ﻛﺒﺎر‬ ‫ﻟﻨﻮﻋﻴﻦ‬ ‫ﻫﻨﻘﺴﻤﻬﺎ‬ IHD ‫ال‬ ‫اﻧﻪ‬ ‫اﻟﺴﺎﺑﻘﺔ‬ ‫ﺑﺎﻟﺒﻮﺳﺘﺎت‬ ‫ﻋﺮﻓﻨﺎ‬
(Chronic Coronary Syndrome(CCS ‫ال‬ ‫ﻫﻮ‬ ‫ﻧﻮع‬ ‫اول‬
(Acute Coronary Syndrome (ACS ‫ال‬ ‫ﻫﻮ‬ ‫اﻟﺘﺎﻧ‬ ‫واﻟﻨﻮع‬
IHD ‫ب‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﺑﺘﺪﺧﻞ‬ ‫اﻟﻠ‬ Causes ‫ال‬ ‫وﺷﻔﻨﺎ‬
Atherosclerosis ‫ال‬ ‫ﻫﻮ‬ ‫ﺳﺒﺐ‬ ‫اﺷﻬﺮ‬ ‫وﻛﺎن‬
atherosclerosis ‫ال‬ ‫ﺳﺒﺒﻬﺎ‬ IHD ‫ال‬ ‫ﺣﺎﻻت‬ ‫ﻣﻦ‬ %90 ‫ف‬
Coronary Lumen‫ال‬ ‫ﻫﺘﻀﻴﻖ‬ atherosclerosis Plaque ‫ال‬ ‫ﻗﺪﻳﺶ‬ ‫ﺣﺴﺐ‬ ‫ﻋﻠ‬ ‫ﺣﺎﻻت‬ ‫ﻷرﺑﻊ‬ IHD ‫ال‬ ‫وﺑﻨﻘﺴﻢ‬
less than 50%
‫ﺧﺎﻟﺺ‬ ‫ﻴﺶ‬‫ﻣﺒﻴﺸﺘ‬ ‫واﻟﻤﺮﻳﺾ‬ Asymptomatic ‫ﻮن‬‫ﻓﺒﻴ‬ %50 ‫ﻣﻦ‬ ‫اﻗﻞ‬ ‫اﻻﻧﺴﺪاد‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬
Obstruction %70-50
At Rest ‫ﻛﺎﻓ‬ ‫اﻟﻘﻠﺐ‬ ‫ﻟﻌﻀﻠﻪ‬ ‫اﻟﻮاﺻﻞ‬ ‫اﻟﺪم‬ ‫ﻮن‬‫ﺑﻴ‬
Chest Pain ‫ﺑﻴﺤﺼﻞ‬ ‫ﻣﺠﻬﻮد‬ ‫أي‬ ‫ﺑﺬل‬ ‫ﺑﻤﺠﺮد‬ ‫ﻦ‬‫ﻟ‬
CCS ‫ال‬ ‫ﺣﺎﻻت‬ ‫ﻓ‬ ‫ﺑﻨﺸﻮﻓﻪ‬ ‫وﻫﺎد‬
70-99% Obstruction
Rest ‫ال‬ ‫ﺧﻼل‬ ‫ﺣﺘ‬ Chest pain ‫ال‬ ‫ﺑﻴﺤﺼﻞ‬
( Obstruction of Lumen 100% ➡Acute MI ( STEMI
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Coronary ‫ال‬ ‫داﺧﻞ‬ atherosclerosis Plaque ‫ال‬ ‫ﻮن‬‫ﺑﺘﺘ‬ ‫ﻛﻴﻒ‬
‫او‬ Endothelium Dysfunction ‫ﻓ‬ ‫ﻟﻮ‬ ‫ﺧﺎﺻﺔ‬ Aretry ‫ال‬ ‫داﺧﻞ‬ ‫وﺑﻴﻠﺰق‬ Oxidation ‫ﺑﻴﺼﻴﺮﻟﻪ‬ (‫اﻟﺴ‬ ‫ﻮﻟﻴﺴﺘﻴﺮول‬‫اﻟ‬ )LDL ‫ال‬
Inflammation
Is an inflammatory fibro-proliferative process Affecting the intimal layer of arteries Leading to
accumulation of cells, lipids, fibrous tissue, and calcium → Resulting in the formation of an
atherosclerotic plaque → Ending with progressive luminal stenosis ( Source : Cardiology secret
(Code
Atherosclerosis ? ‫ﻟﻞ‬ Risk factor ‫ﻫ‬ ‫ﺷﻮ‬ ‫ﻃﻴﺐ‬
Modifiable Risk Factor
Management ‫ﻧﻌﻤﻠﻠﻬﺎ‬ ‫ﺑﻨﻘﺪر‬ ‫اﻟﻠ‬ Risk factor ‫ال‬ ‫ﻫﺎي‬
obesity ‫وال‬ Stress ‫وال‬ Smoking ‫وال‬ DM ‫وال‬ HTN ‫ال‬ ‫زي‬
High LDL level ‫وال‬
Non-Modifiable Risk Factor
‫ﻧﻌﺪﻟﻬﺎ‬ ‫ﺑﻨﻘﺪر‬ ‫ﻣﺎ‬ ‫ﻋﻮاﻣﻞ‬

7. ... menopause ‫ال‬ ‫ﺑﻌﺪ‬ female ‫وال‬ ‫اﻛﺘﺮ‬ male ‫ال‬ ‫ﺑﻴﺼﻴﺐ‬ ‫ﻓﻬﻮ‬ sex ‫وال‬ Family hx ‫وال‬ Old Age ‫ال‬ ‫زي‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

10. Cardiology_62❤#Ischemic_heart_disease_4#
How to prevent Atherosclerosis
... ‫ﻛﺒﻴﺮه‬ ‫ﺑﻨﺴﺒﻪ‬ACS ‫ال‬ ‫ﺣﺪوث‬ ‫ﻫﻨﻤﻨﻊ‬ Atherosclerosis ‫ال‬ ‫ﻣﻨﻌﻨﺎ‬ ‫ﻟﻮ‬
pt :‫ﻟﻞ‬ Risk Stratification ‫ﺑﻨﻌﻤﻞ‬ ‫ﺷ‬ ‫اول‬
Risk Assessment
low risk ‫وﻻ‬ Moderate ‫وﻻ‬ High ‫وﻻ‬ very High Risk ‫ﻫﻮ‬ ‫ﻫﻞ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﺑﻨﺸﻮف‬
Very High Risk
very high risk ‫ﺑﻨﻌﺘﺒﺮه‬ ‫اﻟﺘﺎﻟﻴﻪ‬ ‫اﻟﻨﻘﺎط‬ ‫ﻣﻦ‬ ‫ﻧﻘﻄﻪ‬ ‫ﻋﻨﺪه‬ ‫اﻟﻠ‬ ‫اﻟﻤﺮﻳﺾ‬
1- Documented CVD as previous AMI, ACS, stroke and TIA
2-DM with target organ damage such as proteinuria
3-Severe CKD (GFR < 30 ml/min/1.73 m2)
4-Acalculated 10-year ASCVD score (atherosclerotic Cardiovascular Disease ) >=10%
⭐ Note to Remember
( Medical calculator ‫اي‬ ‫ﻣﻦ‬ ‫ﺑﻴﻨﺤﺴﺐ‬ ) Score ‫ال‬ ‫ﺣﺴﺒﻨﺎ‬ ‫ﻟﻮ‬ ‫اﻧﻮ‬ ‫وﺷﻔﻨﺎ‬ HTN ‫ال‬ ‫ﺑﺒﻮﺳﺘﺎت‬ ‫ﻋﻨﻪ‬ ‫ﻠﻤﻨﺎ‬‫ﺗ‬ ASCVD Score ‫ال‬
Very high risk pt ‫اﻟﻤﺮﻳﺾ‬ ‫ﺑﻨﻌﺘﺒﺮ‬ %10 ‫ﻣﻦ‬ ‫اﻛﺘﺮ‬ ‫اﻟﻘﻴﻤﻪ‬ ‫وﻛﺎﻧﺖ‬
American ‫ال‬ ‫ﺣﺴﺐ‬ Stage1 HTN ‫ال‬ ‫ﺷﺮﺣﻨﺎ‬ ‫ﻣﺎ‬ ‫وﻳﻮم‬
‫ال‬ ‫ﻣﻊ‬ Anti HTN Drug ‫ب‬ ‫ﺑﻨﺒﺪأﻟﻪ‬ %10 ‫ﻣﻦ‬ ‫اﻛﺘﺮ‬ ‫وﻃﻠﻊ‬ ASCVD ‫ال‬ ‫وﺣﺴﺒﻨﺎ‬ 89-80 / 139-130 ‫اﻟﺪم‬ ‫ﺿﻐﻂ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ ‫اﻧﻪ‬ ‫ﺷﻔﻨﺎ‬
Lufe style modification
High Risk
1-Markedly elevated single risk factors, in particular cholesterol >310 mg/dL or BP 180/110 mmHg.
2- Most other people with DM
3-Moderate CKD (GFR 30-59 ml/min/1.73 m2).
4- A calculated SCORE >=5% and <10%
Moderate Risk
1-SCORE is >=1% and < 5% at 10 years ASCVD score
moderate risk ‫ال‬ ‫ﺗﺤﺖ‬ ‫ﺑﻴﻨﺪرﺟﻮ‬ middle aged ‫ال‬ ‫واﻏﻠﺐ‬
Low Risk
ASCVD SCORE is < 1%

11. ⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Life style modifications ‫ال‬ ‫ﻫﻮ‬ ‫ﺷ‬ ‫ﺗﺎﻧ‬
Low Saturated fat ‫ﻓﻴﻪ‬ Diet ‫ال‬ ‫ﻮن‬‫ﻳ‬ ‫اﻧﻪ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﺑﻨﻨﺼﺢ‬
‫واﻻﺳﻤﺎك‬ Grain ‫وال‬ ‫واﻟﻔﻮاﻛﻬﻪ‬ ‫اﻟﺨﻀﺎر‬ ‫ﻣﻦ‬ ‫ﺘﺮ‬‫وﻳ‬
‫ﺑﺎﻻﺳﺒﻮع‬ ‫اﻳﺎم‬ 5 ‫ﺧﻼل‬ ‫دﻗﻴﻘﻪ‬ 30 ‫اﻻﻗﻞ‬ ‫ﻋﻠ‬ ‫اﻟﺮﻳﺎﺿﻪ‬ ‫ﻳﻤﺎرس‬ ‫وﺑﻨﻨﺼﺤﻪ‬
25-20 ‫ﺑﻴﻦ‬ ‫ﻣﺎ‬ ‫ﻮن‬‫ﻳ‬ BMI ‫وزﻧﻪ‬ ‫ﻋﻠ‬ ‫وﻳﺤﺎﻓﻆ‬
140/90 ‫ﻣﻦ‬ ‫اﻗﻞ‬ Bp ‫ال‬ ‫ﻋﻠ‬ ‫وﻳﺤﺎﻓﻆ‬
%7 ‫ﻣﻦ‬ ‫اﻗﻞ‬ hbA1C ‫ال‬ ‫ﻋﻠ‬ ‫وﻧﺤﺎﻓﻆ‬
Risk stage ‫ﺑﺄﻧﻬ‬ ‫ﻫﻮ‬ ‫ﺣﺴﺐ‬ LDL ‫ال‬ ‫ﻋﻠ‬ ‫وﻧﺤﺎﻓﻆ‬
55mg/dl ‫ﻣﻦ‬ ‫اﻗﻞ‬ ‫ﻮن‬‫ﺗ‬ LDL ‫ال‬ ‫ﻗﻴﻤﻪ‬ ‫ﻓﺒﻨﺤﺎول‬ very high Risk ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ ‫ﻳﻌﻨ‬
70mg/dl ‫ﻣﻦ‬ ‫اﻗﻞ‬ ‫ﻮن‬‫ﺗ‬ LDL ‫ال‬ ‫ﻗﻴﻤﺔ‬ ‫ﻋﻠ‬ ‫ﻓﺒﻨﺤﺎﻓﻆ‬ High risk pt ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
100mg/dl ‫ﻣﻦ‬ ‫اﻗﻞ‬ ‫ﻮن‬‫ﺗ‬ ‫اﻻﻓﻀﻞ‬ LDL ‫ال‬ ‫ﻓﻘﻴﻤﻪ‬ Moderate risk pt-‫ال‬ ‫ﺣﺎﻟﺔ‬ ‫وﻓ‬
116mg/dl ‫ﻣﻦ‬ ‫اﻗﻞ‬ ldl ‫ال‬ ‫ﻗﻴﻤﻪ‬ ‫ﻮن‬‫ﻓﺘ‬ low risk ‫ال‬ ‫ﺣﺎﻟﻪ‬ ‫وﻓ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
... ‫ﻪ‬‫اﻟ‬ ‫ﺷﺎء‬ ‫ان‬ ‫ﻻﺣﻘﺎ‬ ‫ﺑﺎﻟﺘﻔﺼﻴﻞ‬ ‫وﻫﻨﺸﻮﻓﻬﺎ‬ Statin therapy ‫ﻧﻌﻄ‬، ‫ﺷ‬ ‫ﺗﺎﻟﺖ‬
Source : cardiology secret code
ESC
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

16. Cardiology_63❤#Ischemic_heart_disease_5#
Chronic Coronary Syndrome #CCS
: ‫اﻟﺘﺎﻟﻴﺔة‬ ‫ﻧﻘﺎط‬ ‫اﻟﺨﻤﺲ‬ ‫ﻓﻴﻬﺎ‬ Syndrome ‫ﻋﻦ‬ ‫ﻋﺒﺎرة‬ CCS ‫ال‬
1⃣Occurance of Chest pain or Discomfort
2⃣with Unchanged characteristic for 60 day
3⃣Caused by Myocardial Ischemia
4⃣ precipitate by Physical or Emotional stress
... 5⃣ Relive by Rest or Sublingual Nitrate
‫وﺑﻴﺨﻒ‬ ‫اﻟﻤﺠﻬﻮد‬ ‫ﻣﻊ‬ ‫وﺑﻴﺰﻳﺪ‬ ‫ﺷﻬﺮﻳﻦ‬ ‫ﺧﻼل‬ ‫ﺗﻐﻴﺮت‬ ‫ﻣﺎ‬ ‫ﺧﺼﺎﺋﺼﻪ‬ Pain ‫ال‬ ‫وﻫﺎد‬ Chest pain ‫ﻣﻦ‬ ‫ﺑﻴﺸﺘ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ ‫ﻳﺒﻘ‬
... CCS ‫ﻮن‬‫ﺑﻴ‬ ‫ﻓﻬﻨﺎ‬ Nitrate ‫ال‬ ‫او‬ ‫اﻟﺮاﺣﻪ‬ ‫ﻣﻊ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
‫اﻧﻮاع‬ 3 ‫ل‬ ‫ﺑﻴﺘﻘﺴﻢ‬ Chest pain ‫ال‬
Typical Anginal Pain
Atypical Anginal Pain
Non Anginal Pain
: ‫اﻟﺘﺎﻟﻴﺔ‬ ‫ﻧﻘﺎط‬ ‫اﻟﺘﻼت‬ ‫ﻓﻴﻪ‬ ‫ﻮن‬‫ﺑﻴ‬ Typical Anginal pain ‫ال‬
.substernal Chest pain ‫ﻓ‬ ‫ﻮن‬‫ﻳ‬
‫اﻟﻤﺠﻬﻮد‬ ‫ﻣﻊ‬ ‫ﺑﻴﺰﻳﺪ‬
Nitrate ‫ال‬ ‫او‬ ‫اﻟﺮاﺣﻪ‬ ‫ﻣﻊ‬ ‫ﺑﻴﺮوح‬
Typical anginal pain ‫ﻮن‬‫ﺑﻴ‬ ‫ﺗﻮﻓﺮو‬ ‫ﻫﺪول‬ ‫ﻧﻘﺎط‬ ‫اﻟﺘﻼت‬ ‫ﻓﻠﻮ‬
Atypical Anginal pain ‫ﻮن‬‫ﺑﻴ‬ ‫ﺗﻼﺗﻪ‬ ‫ﻣﻦ‬ ‫ﻧﻘﻄﺘﻴﻦ‬ ‫ﺗﻮﻓﺮ‬ ‫ﻟﻮ‬
Anginal pain ‫ﻣﺶ‬ ‫ﻮن‬‫ﺑﻴ‬ ‫وﺣﺪه‬ ‫ﻧﻘﻄﻪ‬ ‫ﻟﻮ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Anginal pain ‫ال‬ ‫ﺧﺼﺎﺋﺺ‬ ‫ﻫ‬ ‫ﺷﻮ‬
‫دﻗﻴﻘﻪ‬ 20 ‫ل‬ ‫دﻗﻴﻘﻪ‬ ‫ﻣﻦ‬ ‫وﺑﻴﺴﺘﻤﺮ‬ ‫ﺟﺪاا‬ ‫وﺷﺪﻳﺪ‬ Sudden ‫ﻮن‬‫ﺑﻴ‬
‫دﻗﻴﻘﻪ‬ 20 ‫ﻋﻦ‬ ‫ﻳﺰﻳﺪ‬ ‫وﻻ‬ ‫دﻗﻴﻘﺔ‬ ‫ﻋﻦ‬ ‫ﻳﻘﻞ‬ ‫ﻻ‬
‫دﻗﺎﺋﻖ‬ 5-1 ‫ﻣﻦ‬ ‫ﺑﺘﺴﺘﻤﺮ‬ ‫ﻧﻮﺑﺔ‬ ‫ﻛﻞ‬ Attack ‫ﺻﻮرة‬ ‫ﻓ‬ ‫وﺑﻴﺤﺼﻞ‬
‫ل‬ ‫ﺗﺤﻮل‬ ‫ﻏﺎﻟﺒﺎ‬ ‫ﻮن‬‫ﺑﻴ‬ ‫ﺑﺎﻟﻴﻮم‬ ‫ﻣﺮات‬ 8 ‫ل‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻋﻠ‬ ‫زاد‬ ‫وﻓﺠﺄه‬ ‫ﺑﺎﻟﻴﻮم‬ ‫ﻣﺮات‬ ‫ﺗﻼت‬ ‫ﻛﺎن‬ ‫ﻣﺜﻼ‬ Frequency ‫ال‬ ‫ﻟﻮ‬ )
( Acute Coronary syndrome
Nausea/Vomiting ‫او‬ ‫دوﺧﻪ‬ ‫او‬ ‫ﺗﻌﺮق‬ pain ‫ال‬ ‫ﻳﺼﺎﺣﺐ‬ ‫ﻦ‬‫ﻣﻤ‬
stress ‫أي‬ ‫ﻣﻊ‬ ‫اﻟﻮﺟﻊ‬ ‫ﻫﺎد‬ ‫ﺑﻴﺰﻳﺪ‬
Sexual Intercourse ‫ال‬ ‫او‬ heavy meal ‫او‬ ‫اﻟﺒﺎرد‬ ‫اﻟﺠﻮ‬ ‫او‬ ‫اﻟﺮﻳﺎﺿﻪ‬ ‫ﻣﻊ‬ ‫ﻓﺒﻴﺰﻳﺪ‬
Sublingual nitrate ‫ال‬ ‫او‬ ‫اﻟﺮاﺣﺔ‬ ‫ﻣﻊ‬ ‫وﺑﻴﺮوح‬
Diffused area ‫ﻮن‬‫ﺑﻴ‬ ‫ﺑﻞ‬ ‫واﺣﺪ‬ ‫ﺑﺎﺻﺒﻊ‬ pain ‫ال‬ ‫ﻫﺎد‬ ‫ﻋﻠ‬ ‫ﻳﺸﺎور‬ ‫ﻣﺒﻴﻘﺪرش‬ ‫اﻟﻤﺮﻳﺾ‬
: ‫ﻣﻨﻄﻘﺔ‬ ‫ﺬا‬‫ﺑ‬ ‫ﺑﻴﺴﻤﻊ‬ Pain ‫ال‬

17. ‫اﻟﻴﻤﻴﻦ‬ ‫او‬ ‫اﻟﺸﻤﺎل‬ ‫ﺳﻮاء‬ shoulder ‫ال‬ ‫او‬ Retrosternal ‫ال‬ ‫ﺑﻤﻨﻄﻘﻪ‬ ‫ﻳﺴﻤﻊ‬ ‫ﻦ‬‫ﻣﻤ‬
Inner aspect of arm ‫ال‬ ‫او‬
little finger ‫ال‬ ‫او‬
Root of neck ‫ال‬ ‫او‬
Lower jaw ‫ال‬ ‫او‬
Back ‫ال‬ ‫او‬
Epigastric ‫ال‬ ‫ﻣﻨﻄﻘﻪ‬ ‫او‬
??Chest pain ‫ﻣﻌﻪ‬ ‫وﻣﻴﺤﺼﻠﺶ‬ Ischemia ‫ﻋﻨﺪه‬ ‫ﻮن‬‫ﻳ‬ ‫ﻣﺮﻳﺾ‬ ‫ﻦ‬‫ﻣﻤ‬ ‫ﻫﻞ‬ ‫ﺑﻬﻠﻤﻌﻠﻮﻣﻪ‬ ‫اﻟﺒﻮﺳﺖ‬ ‫ﻧﺨﺘﻢ‬
Chest pain ‫ﺑﺪون‬ Coronary Ischemia ‫ﻓ‬ ‫ﻮن‬‫ﻳ‬ ‫ﻦ‬‫ﻣﻤ‬ ‫ﺣﺎﻟﺘﻴﻦ‬ ‫ﻋﻨﺎ‬ ‫ﻓ‬
( 1⃣painless Ischemia ( Angina Equivalent
fatigue ‫او‬ Dyspnea ‫او‬ nausea ‫او‬ ‫دوﺧﻪ‬ ‫او‬ ‫ﺗﻌﺮق‬ ‫ﻦ‬‫ﻣﻤ‬ Symptoms ‫ﻓ‬ ‫ﻮن‬‫ﻫﻴ‬ ‫ﺑﺲ‬ pain ‫ﻣﻦ‬ ‫ﻫﻴﺸﺘ‬ ‫ﻣﺶ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻫﻨﺎ‬
‫ﻗﻠﺐ‬ ‫زراﻋﻪ‬ ‫ﻋﺎﻣﻠﺔ‬ ‫اﻟﻠ‬ ‫اواﻟﺤﺎﻻت‬ Old age ‫ال‬ ‫او‬ DM ‫ال‬ ‫ﻣﺮﻳﺾ‬ ‫ﻣﻊ‬ ‫ﻏﺎﻟﺒﺎ‬ ‫ﻮن‬‫ﺑﻴ‬ ‫وﻫﺎد‬
Silent Ischemia 2⃣
Symptoms ‫ﺑﺪون‬ ‫وﻛﻤﺎن‬ pain ‫ﺑﺪون‬ ‫ﺑﺲ‬ Coronary ischemia ‫ﻓ‬ ‫ﻮن‬‫ﺑﻴ‬
source : Cardiology secret code ,ESC ,BMJ
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

19. Cardiology_64 #Ischemic_heart_disease_6#
(Management Guideline for Stable Angina according to American guideline (ACC/AHA
‫أدوﻳﺔ‬ ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ Stable Angina ‫إﻧﻪ‬ ‫ﻋﻠ‬ ‫اﺗﺸﺨﺺ‬ ‫ﻣﺮﻳﺾ‬ ‫أي‬
Prognosis ‫ال‬ ‫ﻣﻦ‬ Prevention ‫وﻗﺎﺋﻴﺔ‬ ‫وأدوﻳﻪ‬ ( Symptom Relief ( Anti-Ischemia ‫ﻟﻸﻋﺮاض‬
... ‫ﺮ‬‫واﻟﺴ‬ ‫اﻟﻀﻐﻂ‬ ‫وﺗﺰﺑﻴﻂ‬ Life style modification ‫ﻟﻞ‬ ‫ﺑﺎﻹﺿﺎﻓﺔ‬
Drug for Event Prevention
Lipid lowering Drug ‫وال‬ Antiplatlet ‫ال‬ ‫زي‬
( Symptom Relief Drug ( Anti-Ischemia drug
CCB ‫وال‬ BB ‫ال‬ ‫وزي‬ Short acting nitrate ‫ال‬ ‫زي‬
‫ﻫﻠﺒﻮﺳﺖ‬ ‫ﺧﻼل‬ American ‫ال‬ ‫ﺣﺴﺐ‬ guideline management ‫ال‬ ‫ﻪ‬‫اﻟ‬ ‫ﺷﺎء‬ ‫ان‬ ‫⭐ﻫﻨﺸﻮف‬
European Guideline ‫ال‬ ‫ﻫﻨﺸﻮف‬ ‫اﻟﻘﺎدﻣﻪ‬ ‫واﻟﺒﻮﺳﺘﺎت‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Drug Used for Event prevention ...
1⃣ Anti- Platlet
‫ال‬ ‫ﺑﻨﻤﻨﻊ‬ ‫وﺑﺎﻟﺘﺎﻟ‬ Atherosclerosis plaque ‫ال‬ ‫ﻋﻠ‬ platlet aggregation ‫ال‬ ‫ﻧﻤﻨﻊ‬ ‫ﻫﻮ‬ Antiplatlet ‫ال‬ ‫ﻣﻦ‬ ‫اﻟﻐﺮض‬
Coronary narrowing
Aspirin ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ Stable angina ‫ﻣﺮﻳﺾ‬ ‫اي‬
Clopidogrel ... ‫ﻋﻠ‬ ‫ﻣﻨﻪ‬ ‫ﺑﺪﻻ‬ ‫ﻓﺒﻴﻤﺸ‬ Contraindicated ‫اﻻﺳﺒﺮﻳﻦ‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
All patients should be started on aspirin and this should be continued indefinitely.
use aspirin 75-162 mg once daily indefinitely in absence of contraindications (ACCF/AHA Class I,
Level A), or clopidogrel if aspirin contraindicated (ACCF/AHA Class I, Level B)
In patients with SIHD ( Stable Ischemic Heart Disease) without prior history of ACS, coronary stent
implantation, or recent (within 12 months) CABG, treatment with DAPT ( Dual antiplatlet therapy ) is
.not beneficial
‫ﺷﺮح‬ ‫ﻣﻊ‬ ‫ﻻﺣﻘﺎا‬ ‫ﺣﻨﺸﻮﻓﻬﺎ‬ ‫ﻣﻌﻴﻨﻪ‬ ‫وﻟﻔﺘﺮة‬ ‫دﻋﺎﻣﺎت‬ ‫رﻛﺐ‬ ‫اﻟﻠ‬ ‫ﻟﻠﻤﺮﻳﺾ‬ ‫ﻮن‬‫ﺑﺘ‬ Dual antiplatlet therapy ‫ع‬ ‫ﻫﺘﻤﺸ‬ ‫اﻟﻠ‬ ‫اﻟﺤﺎﻻت‬
ACS .. ‫ال‬
... 2⃣ lipid Lowering Drug
High dose ‫ب‬ ‫واﻻﻓﻀﻞ‬ Statins ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ SIHD ‫ﻣﺮﻳﺾ‬ ‫اي‬
shrinking ‫وﺑﻨﻌﻤﻠﻠﻬﺎ‬ Atherosclerosis plaque ‫ال‬ ‫ﻧﻘﻠﻞ‬ ‫اﻧﻪ‬ ‫واﻟﻐﺮض‬

20. In addition to lifestyle changes, use moderate or high-dose statin if not contraindicated (ACCF/AHA
Class I, Level A), or consider bile acid sequestrants, niacin, or both if statins not tolerated
( ‫اﻟﺼﻮر‬ ‫ﻣﻊ‬ ‫ﻣﺮﻓﻘﺔ‬ ‫اﻟﺠﺮﻋﺎت‬ )
SE ‫ﻣﻌﻪ‬ ‫ﺻﺎر‬ ‫او‬ Statin ‫ال‬ ‫ﻣﺘﺤﻤﻞ‬ ‫ﻣﺶ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻓﺮﺿﺎ‬ ‫ﻃﻴﺐ‬
For patients who do not tolerate statins, low-density lipoprotein-cholesterol lowering therapy with
bile acid sequestrants,* niacin, or both is reasonable.
Note ⛔*The use of bile acid sequestrant is relatively contraindicated when triglycerides are ≥200
.mg/dL and is contraindicated when triglycerides are ≥500 mg/dL
Anti Ischemia drug ‫ال‬ ‫ﻣﻊ‬ ‫ﻤﻞ‬‫ﺑﻨ‬ ‫اﻟﻘﺎدم‬ ‫واﻟﺒﻮﺳﺖ‬ ‫ﻫﻨﺎ‬ ‫ﻟﺤﺪ‬ ‫ﻧﻮﻗﻒ‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

25. Cardiology_65 #Ischemic_heart_disease_7#
... Management Guideline for Stable Angina according to American guideline (ACC/AHA) part 2
Class 1 ‫اﻻﺳﺒﺮﻳﻦ‬ ‫وﻛﺎن‬ Antiplatlet Drug ‫ع‬ ‫ﻫﻴﻤﺸ‬ Stable Angina ‫ال‬ ‫ﻣﺮﻳﺾ‬ ‫ان‬ ‫اﻟﺴﺎﺑﻖ‬ ‫اﻟﺒﻮﺳﺖ‬ ‫ﺷﻔﻨﺎ‬
Recommendation
‫اﻻﺳﺒﺮﻳﻦ‬ ‫اﺳﺘﺨﺪام‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
clopidogrel ‫ال‬ ‫ﻫﻮ‬ ‫اﻟﻠ‬ ‫ﺑﺪﻳﻠﻪ‬ ‫ﻓﺒﻴﺎﺧﺪ‬
Lipid lowering Drug ‫ﻟﻞ‬ ‫ﺑﺎﻹﺿﺎﻓﺔ‬
High- Moderate Intensity Statin ‫ب‬ ‫ﺑﻴﺒﺪأ‬
‫ﻟﻞ‬ ‫ﺑﻴﻠﺠﺄ‬ ‫اﺳﺘﺨﺪاﻣﻬﻢ‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
Bile acid sequestrant
.... ‫ﺣﺎﻟﺘﻪ‬ ‫ﺗﻄﻮر‬ ‫او‬ ACS ‫ال‬ ‫ﺣﺪوث‬ ‫ﻟﻤﻨﻊ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻫﻴﺎﺧﺪﻫﻢ‬ Prevention Event drug ‫ﺑﻨﺪ‬ ‫ﺗﺤﺖ‬ ‫ﻛﺎﻧﺖ‬ ‫اﻻدوﻳﻪ‬ ‫ﻓﻬﺪول‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Anti-Ischemia drug ‫ال‬ ‫ﻫ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻋﻠﻴﻬﺎ‬ ‫ﻫﻴﻤﺸ‬ ‫ﻣﺠﻤﻮﻋﻪ‬ ‫ﺗﺎﻧ‬
‫ال‬ ‫زي‬
Short Acting Nitrate(Nitroglycerin) 1⃣
( SAN)
2⃣ BB
3⃣CCB
4⃣Long Acting Nitrate ( LAN)
5⃣Ranolazine
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
1⃣ SAN
chest pain ‫ال‬ ‫ﻳﺠﻴﻠﻪ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻣﺎ‬ ‫وﻗﺖ‬ ‫ﺑﻤﻌﻨ‬ Immediate Pain relief ‫ال‬ ‫ﻋﻠ‬ ‫ﻳﻘﺘﺼﺮ‬ ‫دوره‬ SAN‫ال‬
lingual Spray ‫او‬ Sublingual ‫ﺳﻮاء‬ SAN ‫ﻫﻴﺎﺧﺪ‬
Note: If pain is not relieved or worsens 3 to 5 minutes after 1 sublingual or translingual dose, seek
immediate emergency medical attention
: ‫ﺟﺮﻋﺎﺗﻪ‬
Sublingual powder (0.4 mg/packet): Initial: 1 or 2 packets at onset; repeat every 5 minutes if
angina persists; may administer up to 3 packets in a 15-minute period
Sublingual tablet: Initial: 0.3 or 0.4 mg at onset; repeat every 5 minutes if angina persists; may
administer up to 3 tablets in a 15-minute period
For patients with refractory angina in the emergency department, up to 0.6 mg as a single dose may
be considered
Translingual 0.4 mg/spray: Initial: 1 or 2 sprays at onset; repeat every 5 minutes if angina persists;
may administer up to 3 sprays in a 15-minute period
(2⃣ Beta Blocker ( BB
Anti-Ischemia ‫ك‬ 1st Choise ‫ال‬ ‫ﻫﻮ‬ BB ‫ال‬
... Contraindicated ‫ﻦ‬‫ﻳ‬ ‫ﻟﻢ‬ ‫ﻣﺎ‬

26. ‫اﻟﺪم‬ ‫ﻤﻴﻪ‬‫ﺑ‬ ‫ﺘﻔ‬‫وﻫﻴ‬ Cardiac Demand ‫ال‬ ‫ﻫﻴﻘﻞ‬ ‫ﺑﺎﻟﺘﺎﻟ‬ Contractility ‫وال‬ HR ‫ال‬ ‫ﺗﻘﻠﻴﻞ‬ ‫ﻫﻮ‬ BB ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻣﻦ‬ ‫اﻟﻐﺮض‬
‫اﻟﻪ‬ ‫اﻟﻮاﺻﻠﻪ‬
.. 60beat/min-55 ‫ل‬ HR ‫ال‬ ‫ﻧﻮﺻﻞ‬ ‫اﻧﻪ‬ ‫واﻟﻬﺪف‬
‫ﺳﻨﻮات‬ ‫ﺛﻼث‬ ‫ﻟﻤﺪة‬ BB ‫ال‬ ‫ﻋﻠ‬ ‫ﻫﻴﺴﺘﻤﺮ‬ ACS ‫او‬ MI ‫ل‬ ‫وﺗﻌﺮض‬ Normal LV Function ‫ﻋﻨﺪه‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬
European ‫وال‬ American ‫ال‬ ‫ﺑﻴﻦ‬ ‫اﻟﻔﺮق‬ ‫وﻫﻨﺎ‬
‫اﻟﻌﻤﺮ‬ ‫ﻃﻮل‬ BB ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻋﻠ‬ ‫ﺑﻴﻌﺘﻤﺪو‬ European ‫ﻓﺎل‬
US guidelines recommend starting beta-blocker therapy and continuing for 3 years in all patients
after MI or acute coronary syndrome. European guidelines suggest consideration of long-term
therapy after ST-elevation MI
HF / Prior MI ‫ال‬ ‫ﻣﺮﻳﺾ‬ ‫زي‬ %40 ‫ﻣﻦ‬ ‫اﻗﻞ‬ Ejection fraction ‫ال‬ ‫وﻛﺎن‬ LV dysfunction ‫ﻋﻨﺪه‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬
: ‫اﻟﺘﺎﻟﻴﺔ‬ BB ‫ال‬ ‫ﻣﻦ‬ ‫واﺣﺪ‬ ‫ﻫﻴﺴﺘﺨﺪم‬ ‫ﻫﻨﺎ‬
Bisoprolol ,Carvidelol ,Metoprolol succinate
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

28. Cardiology_66 #Ischemic_heart_disease_8#
...Management Guideline for Stable Angina according to American guideline (ACC/AHA) part 3
CCBs .. ‫ال‬ ‫ﻫ‬ Anti-Ischemia ‫ال‬ ‫أدوﻳﺔ‬ ‫ﻣﻦ‬ ‫ﻣﺠﻤﻮﻋﺔ‬ ‫ﺗﺎﻧ‬
A beta-blocker is the preferred initial therapy; if there are ongoing symptoms on beta-blocker
therapy, a long acting dihydropyridine calcium channel blocker (eg, amlodipine ,ER nifedipine) may
be added; amlodipine or ER nifedipine may also be used as an alternative therapy if there are
contraindications or unacceptable adverse effects with beta-blockade
2ed line Anti-Ischemia ‫ﺗﻌﺘﺒﺮ‬ CCB ‫ال‬ ‫ﻳﺒﻘ‬
BB ‫ﻟﻞ‬ Tolerated ‫ﻣﺶ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻓﻠﻮ‬
CCB ‫ﻟﻞ‬ ‫ﺑﻴﻠﺠﺄ‬
‫ال‬ ‫ﺑﻴﻨﻀﺎف‬ ‫ﺑﻬﻠﺤﺎﻟﻪ‬ ‫اﻟﻤﻄﻠﻮب‬ Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫وﻣﺎ‬ BB ‫ع‬ ‫ﻣﺸ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬ ‫او‬
BB ‫ال‬ ‫ﻣﻊ‬ Dihydropyridine CCB
Amlodipine : Oral: 5 to 10 mg once daily.
ER nifedipine : Oral: Extended release: Initial: 30 or 60 mg once daily; increase as needed to
effective antianginal dose over 1 to 2 weeks. Doses >90 mg/day are rarely needed; maximum: 120
.mg/day
Tolerated ‫ﻣﺶ‬ BB ‫ال‬ ‫ﻟﻮ‬ BB ‫ﻟﻞ‬ ‫ﻛﺒﺪﻳﻞ‬ ‫ﺗﺴﺘﺨﺪم‬ ‫ﻦ‬‫ﻣﻤ‬ Non-Dihydropyridine CCBs ‫ال‬
Class 2a ; level B
Verapamil :
Immediate release: Initial: 80 to 120 mg 3 times daily; increase as needed at ≥1- to 2-day intervals
to effective antianginal dose; maximum dose: 480 mg/day in 3 divided doses
Extended release: Initial: 180 mg once daily; increase as needed at 7- to 14-day intervals to effective
antianginal dose; maximum dose: 480 mg/day in 1 to 2 divided doses
Diltiazime :
Immediate release: Initial: 30 mg 4 times daily; increase as needed at 1- to 2-day intervals to
effective antianginal dose; usual effective dose: 240 to 360 mg/day in 3 to 4 divided doses
12-hour (twice-daily) formulations (off label): Initial: 60 mg twice daily; increase as needed at 7- to
14-day intervals to effective antianginal dose; usual effective dose: 240 to 360 mg/day in 2 divided
doses
24-hour (once-daily) formulations: Initial 120 to 180 mg once daily; increase as needed at 7- to 14-
day intervals to effective antianginal dose; usual effective dose: 240 to 360 mg/day
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

31. Cardiology_67 #
#Ischemic_heart_disease_9
CCB ‫وال‬ BB ‫وال‬ SAN ‫ال‬ ‫ﻫﻢ‬ ‫اﻟﻠ‬ Anti Ischemia ‫ال‬ ‫ﻣﻦ‬ ‫ﻣﺠﻤﻮﻋﺎت‬ ‫ﺗﻼت‬ ‫اﻟﺴﺎﺑﻖ‬ ‫اﻟﺒﻮﺳﺖ‬ ‫ﺧﻠﺼﻨﺎ‬
BB ‫ال‬ ‫ﻫﻮ‬ American guidelines ‫ال‬ ‫ﺣﺴﺐ‬ 1st line ‫ال‬ ‫وﻛﺎن‬
BB ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫ﺣﺎل‬ ‫ﻓ‬ ‫ﻓﺘﺴﺘﺨﺪم‬ CCB ‫ال‬ ‫اﻣﺎ‬
‫ﻟﻮﺣﺪه‬ ‫ﻛﺎﻓ‬ ‫ﻣﺶ‬ BB ‫ال‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ BB ‫ﻟﻞ‬ CCB ‫ال‬ ‫ﺑﻨﻀﻴﻒ‬ ‫او‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
(Long-Acting Nitrate( LAN ‫ال‬ ‫ﻫ‬ Anti-Ischemia drug ‫ال‬ ‫ﻣﻦ‬ ‫ﻣﺠﻤﻮﻋﻪ‬ ‫راﺑﻊ‬
:‫اﻟﺤﺎﻟﺘﻴﻦ‬ ‫ﺑﻬﺪول‬ ‫ﻧﺴﺘﺨﺪﻣﻬﺎ‬ ‫ﻦ‬‫ﻣﻤ‬ LAN ‫ال‬
If beta blockers clearly contraindicated or cause unacceptable adverse events (ACCF/AHA Class I,
Level B)
in combination with beta-blockers when beta blockers alone are unsuccessful (ACCF/AHA Class
(I,Level B
Isosorbide Mononitrate ‫ال‬ ‫ﻧﺴﺘﺨﺪم‬ ‫ﻦ‬‫ﻣﻤ‬
Oral Isosoebide Dinitrate ‫ال‬ ‫او‬
LAN ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ ‫ﻣﺮﻳﺾ‬ ‫ﻷي‬ ‫ﺟﺪا‬ ‫ﺟﺪا‬ ‫ﺟﺪا‬ ‫ﻣﻬﻤﺎت‬ ‫ﻧﻘﻄﺘﻴﻦ‬ ‫ﻋﻨﺎ‬ ‫ﻓ‬
‫ﺑﺴﺮﻋﺔ‬ Tolerance ‫ﺑﻴﺼﻴﺮﻟﻬﺎ‬ ‫اﻟﻠ‬ ‫اﻷدوﻳﺔ‬ ‫ﻣﻦ‬ Nitrate ‫ال‬ 1⃣
‫ﺳﺎﻋﻪ‬ 12 ‫ﻛﻞ‬ Isosorbide Mononitrate 20mg ‫ع‬ ‫ﻣﺎﺷ‬ ‫ﻛﺎن‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬ ‫ﺑﻤﻌﻨ‬
.. Nitrate ‫ال‬ ‫ﻋﻠ‬ ‫ﻣﺎﺷ‬ ‫اﻧﻪ‬ ‫رﻏﻢ‬ Chest pain ‫ﻣﻦ‬ ‫ﻳﺸﺘ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻫﻴﺮﺟﻊ‬ ‫ﻓﺘﺮة‬ ‫ﺑﻌﺪ‬
Nitrate Tolerance ‫ال‬ ‫ﻫﻮ‬ ‫واﻟﺴﺒﺐ‬
?? Tolerance ‫ال‬ ‫ﺑﺘﺼﻴﺮ‬ ‫ﻛﻴﻒ‬ ‫ﻃﻴﺐ‬
‫ال‬ ‫ﻋﻦ‬ ‫اﻟﻤﺴﺌﻮل‬ Nitric oxide ‫ل‬ ‫اﻟﻨﻴﺘﺮات‬ ‫وﺑﻴﺘﺤﻮل‬ MALDH ‫اﺳﻤﻪ‬ ‫اﻧﺰﻳﻢ‬ ‫ﻋﺒﺮ‬ ‫ﺑﻴﺘﺄﻛﺴﺪ‬ ‫اﻟﺠﺴﻢ‬ ‫ﻳﺪﺧﻞ‬ ‫ﻟﻤﺎ‬ Nitrate ‫ال‬
Heart ‫ال‬ ‫وﺑﻴﺮﻳﺢ‬ Preload ‫ال‬ ‫ﺑﻴﻘﻠﻞ‬ ‫وﺑﺎﻟﺘﺎﻟ‬ VenoDilatation ‫ﺗﺤﺪﻳﺪا‬ Vasodilation effect
‫وﺑﻴﻌﻄﻠﻪ‬ MALDH ‫ال‬ ‫اﻧﺰﻳﻢ‬ ‫ﻳﺄﻛﺴﺪ‬ ‫ﺑﻴﺮوح‬ ‫ﺑﺎﻟﺠﺴﻢ‬ ‫ﺗﺮاﻛﻤﻪ‬ ‫ﻣﻊ‬ Nitric oxide ‫ال‬ ‫اﻧﻪ‬ ‫وﺟﺪو‬ ‫ف‬
Nitric oxide ‫ال‬ ‫ﻫﻮ‬ ‫اﻟﻠ‬ Active form ‫ﻟﻞ‬ ‫ﻳﺘﺤﻮل‬ ‫ﻫﻴﻘﺪر‬ ‫ﻣﺶ‬ ‫اﻟﻨﻴﺘﺮات‬ ‫ﺑﺎﻟﺘﺎﻟ‬
‫اﻟﻌﻼج‬ ‫ﺑﻴﺎﺧﺪ‬ ‫ﻣﺎ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺄﻧﻪ‬ ‫ف‬
Nitrate free interval ‫ﻋﻤﻞ‬ ‫ﻫﻮ‬ Nitrate Tolerance ‫ال‬ ‫ﻟﻤﻨﻊ‬ ‫ﺑﺴﻴﻂ‬ ‫ﺣﻞ‬ ‫ﻓ‬ ‫ﻫﻴﻚ‬ ‫ﻋﺸﺎن‬
‫ﺳﺎﻋﻪ‬ 12 ‫ﻛﻞ‬ ‫ﻣﺶ‬ ‫اﻟﻨﻴﺘﺮات‬ ‫ﺟﺮﻋﻪ‬ ‫ﻧﺨﻠ‬
‫ﺳﺎﻋﺎت‬ 7 ‫ﻛﻞ‬ ‫ﺑﻞ‬
‫ﺻﺒﺎﺣﺎ‬ 8 ‫اﻟﺴﺎﻋﻪ‬ ‫ﻛﺎﻧﺖ‬ ‫اﻻوﻟ‬ ‫اﻟﺠﺮﻋﻪ‬ ‫ﻓﻠﻮ‬
‫ء‬‫ﻣﺴﺎ‬ 3 ‫اﻟﺴﺎﻋﺔ‬ ‫ﻮن‬‫ﺗ‬ ‫اﻟﺘﺎﻧﻴﻪ‬ ‫اﻟﺠﺮﻋﻪ‬
Nitrate ‫ال‬ ‫ﻣﻦ‬ free ‫اﻟﺠﺴﻢ‬ ‫ﻮن‬‫ﻳ‬ ‫اﻟﻴﻮم‬ ‫وﺑﺎﻗ‬
MALDH ‫ﻟﻞ‬ Regeneration ‫ﻳﺼﻴﺮ‬ ‫ﺑﺤﻴﺚ‬

32. LAN ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ ‫اﻟﻠ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻋﻠ‬ ‫ﺑﻨﻨﺒﻪ‬ 2⃣
Sildenafil... ‫ال‬ ‫زي‬ PDE5 Inhibitor ‫ﻣﻌﻪ‬ ‫ﻳﺎﺧﺪ‬ ‫ﻣﺎ‬
⛔Concurrent use of phosphodiesterase 5 (PDE5) inhibitors with an organic nitrate is contraindicated
nitrate doses should not be given within at least 24 hours of sildenafil or vardenafil, and nitrates
should not be given within at least 48 hours of tadalafil.
Nitrate may be administered at least 12 hours after the last avanafil dose was ingested, but only
.with close medical supervision and monitoring
LAN ‫ﻟﻞ‬ ‫ﺑﺎﻟﺠﺮﻋﺎت‬ ‫ﻧﺨﺘﻢ‬
Isosorbide Mononitrate :
Immediate release: 20 mg twice daily with the 2 doses given 7 hours apart (eg, 8 AM and 3 PM) to
decrease tolerance development; patients with small stature may initiate therapy with 5 mg twice
daily and titrate to at least 10 mg twice daily in first 2 to 3 days of therapy.
Extended release: Initial: 30 to 60 mg once daily in the morning; may titrate after several days to
120 mg once daily; rarely, 240 mg once daily may be required
Isosorbide Dinitrate
Oral:
Immediate release: Initial: 5 to 20 mg 2 to 3 times daily; Maintenance: 10 to 40 mg 2 to 3 times daily
or 5 to 80 mg
2 to 3 times daily
Sustained release: 40 to 160 mg/day has been used in clinical trials (a nitrate free interval of >18
hours is recommended; however, a clinically efficacious dosage interval has not been clearly
established) or 40 mg 1 to 2 times daily
.(Maximum dose: 160 mg/day (Dilatrate-SR only
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

34. Cardiology_68 #Ischemic_heart_disease_10#
... Management Guideline for Stable Angina according to American guideline (ACC/AHA) part 5
Prevention ttt ‫ك‬ Statin ‫و‬ Aspirin ‫ع‬ ‫ﻣﺸ‬ SIHD ‫ال‬ ‫ﻣﺮﻳﺾ‬ ‫ﻟﻮ‬
.. chest pain ‫ﺑﻴﺠﻴﻠﻪ‬ ‫وﻟﺴﺎﺗﻪ‬ ‫اﻟﻤﻄﻠﻮب‬ Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫وﻣﺎ‬ Anti Ischemia ‫ك‬ BB ‫ع‬ ‫وﺑﺪأ‬
‫اﻟﺴﺎﺑﻖ‬ ‫اﻟﺒﻮﺳﺖ‬ ‫وﺷﻔﻨﺎﻫﻢ‬ LAN ‫او‬ CCB ‫ﻟﻠﻤﺮﻳﺾ‬ ‫ﻳﻨﻀﺎف‬ ‫ﻦ‬‫ﻣﻤ‬ ‫ﺑﻬﻠﺤﺎﻟﺔ‬
CCB ‫ال‬ ‫او‬ LAN ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫أو‬ Response ‫ﻣﺶ‬ ‫ﻟﺴﻪ‬ ‫ﺑﺮدو‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬ ‫ﻃﻴﺐ‬
Ranolazine ... ‫ال‬ ‫ﺑﻨﺴﺘﺨﺪم‬ ‫ﺑﻬﻠﺤﺎﻟﺔ‬
Oral: Initial: 500 mg twice daily; may increase to 1,000 mg twice daily as needed (based on
symptoms); maximum recommended dose: 1,000 mg twice daily
... Anti- Ischemia drug ‫ك‬ Ranolazine ‫ال‬ ‫ﺑﻴﺸﺘﻐﻞ‬ ‫ﻛﻴﻒ‬
‫ال‬ ‫ﻳﺤﻔﺰ‬ ‫ﺑﻴﺮوح‬ ‫ﻳﺘﺤﺮر‬ ‫ﻟﻤﺎ‬ ‫ﺎﻟﺴﻴﻮم‬‫اﻟ‬ ‫وﻫﺎد‬ ‫ﻛﺎﻟﺴﻴﻮم‬ ‫ﻣﺨﺰﻧﺔ‬ ‫ﺑﺘﺒﻘ‬ (sarcoplasmic reticulum ( SR ‫ال‬ ‫اﻧﻪ‬ ‫اﻟﻤﻌﺮوف‬ ‫ﻣﻦ‬
Cardiac work ‫ال‬ ‫وﺑﻴﺰود‬ Contraction ‫ال‬ ‫ﻋﻠ‬ Cardiac cell
‫؟؟‬ ‫ﻓﻴﻬﺎ‬ ‫اﻟﻠ‬ Ca ‫ال‬ ‫ﺗﺨﺮج‬ ‫اﻧﻬﺎ‬ SR ‫ال‬ ‫ﺑﻴﺤﻔﺰ‬ ‫اﻟﻠ‬ ‫ﻣﻴﻦ‬ ‫ﻃﻴﺐ‬
‫اﻟﺼﻮدﻳﻮم‬ ‫ﻫﻮ‬ ‫ﺑﻴﺤﻔﺰﻫﺎ‬ ‫اﻟﻠ‬
‫ﺑﻴﺼﻴﺮ‬ ‫وﺑﺎﻟﺘﺎﻟ‬ Ca ‫ﺗﻔﺮز‬ ‫ﺑﻴﺤﻔﺰﻫﺎ‬ SR ‫ال‬ ‫ﻋﻠ‬ ‫وﺑﻴﺮوح‬ Cardiac cell ‫ال‬ ‫ﻟﺪاﺧﻞ‬ Na channel ‫ال‬ ‫ﻣﻦ‬ ‫ﺑﻴﺪﺧﻞ‬ ‫ﻓﺎﻟﺼﻮدﻳﻮم‬
Contraction
Cardiac work ‫ال‬ ‫ﻧﻘﻠﻞ‬ ‫اﻧﻨﺎ‬ Ischemia ‫ال‬ ‫ﻣﺮﻳﺾ‬ ‫ﻓ‬ ‫ﻫﺪﻓﻨﺎ‬
‫واﺻﻼﻟﻪ‬ ‫اﻟﻠ‬ ‫اﻟﺪم‬ ‫ﺑﺸﻮﻳﺔ‬ ‫ﻳﺸﺘﻐﻞ‬ ‫ﻳﻘﺪر‬ ‫ﺑﺤﻴﺚ‬ ‫اﻟﻘﻠﺐ‬ ‫وﻧﻬﺪي‬
‫ﻓ‬ ‫ﻫﻴﺒﻘ‬ ‫ﻣﺶ‬ ‫ﻓﺒﺎﻟﺘﺎﻟ‬ Cardiac cell ‫ال‬ ‫ﻓ‬ ‫اﻟﻤﻮﺟﻮدة‬ ‫اﻟﺼﻮدﻳﻮم‬ ‫ﻗﻨﻮات‬ ‫اﻏﻼق‬ ‫ﻫﻮ‬ Ranolazine ‫ﻟﻞ‬ Main mechanism ‫ﻓﺎل‬
SR ‫ال‬ ‫ﻣﻦ‬ Ca ‫ال‬ ‫ﻻﻓﺮاز‬ ‫ﻣﺤﻔﺰ‬
... Cardiac Work ‫ال‬ ‫ﻓﻬﻴﻘﻞ‬
Cell necrosis ‫ال‬ ‫ﺑﻴﺰود‬ Ca ‫ال‬، ‫ﺬﻛﺮ‬‫ﻳ‬ ‫ﺑﺎﻟﺸ‬ ‫واﻟﺸ‬
‫ﺗﻤﻮت‬ ‫اﻧﻬﺎ‬ ‫ﻣﻦ‬ ‫اﻟﻘﻠﺐ‬ ‫ﺧﻼﻳﺎ‬ ‫ﻫﻨﺤﻤ‬ Ca ‫ال‬ ‫ﻧﻘﻠﻞ‬ ‫ﻓﻠﻤﺎ‬
Cytoprotective ‫ﻳﻌﺘﺒﺮ‬ Ranolazine ‫ال‬ ‫ﻳﺒﻘ‬
Ranolazine ‫ال‬ ‫ع‬ ‫اﺳﺘﺠﺎب‬ ‫ﻣﺎ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬ ‫ﻃﻴﺐ‬
... Revascularization ‫ﻟﻞ‬ ‫ﺑﻨﻠﺠﺄ‬ ‫ﻫﺘﺎ‬
SIHD ‫ال‬ ‫ﻟﺤﺎﻻت‬ American guideline ‫ال‬ ‫ﺧﻠﺼﻨﺎ‬ ‫ﻫﻴﻚ‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

37. Cardiology_69 #Ischemic_heart_disease_11#
European Society of Cardiology ESC Management
... Guideline for Stable Angina part 1
... ‫ﻟﻤﺠﻤﻮﻋﺘﻴﻦ‬ ‫اﻷدوﻳﺔ‬ ‫ﺑﻴﻘﺴﻤﻮ‬ ACA ‫ال‬ ‫ﻧﻔﺲ‬ ‫ﺑﺮدو‬ stable angina ‫ال‬ ‫ﻋﻼج‬ ‫ﻓ‬ ESC Guideline ‫ال‬
Drug to Reduce angina symptoms
BB,CCB,LAN,Ranolazine ,Nicorandil ,Trimetazidine
Drug to Prevent cardiovascular events.
Aspirin / Clopidogrel ,Statin , ezetimibe , PCSK9 inhibtor
American ‫ال‬ ‫ﻣﻊ‬ ‫اﻧﺬﻛﺮت‬ ‫وﻣﺎ‬ ESC ‫ﺑﺎل‬ ‫اﻧﺬﻛﺮت‬ ‫اﻟﻠ‬ ‫اﻷدوﻳﺔ‬ ‫ﻣﻦ‬
PCSK9 inhibtor ‫وال‬ Ivabradine ‫وال‬ Trimetazidine ‫وال‬ Nicorandil ‫ال‬ ‫ﻫ‬
... ‫ﻻﺣﻘﺎا‬ ‫ﺑﺎﻟﺘﻔﺼﻴﻞ‬ ‫وﺣﻨﺸﻮﻓﻬﻢ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Drug to Reduce angina symptoms
Heart Rate ,Bp ,LV function ‫ال‬ ‫ﻋﻠ‬ ‫اﻋﺘﻤﺪو‬ European ‫ال‬
LAN ‫وﻻ‬ CCB ‫وﻻ‬ ‫اﻟﺒﺪاﻳﺔ‬ ‫ﻣﻦ‬ BB ‫ﻋﻠ‬ ‫ﻫﻴﻤﺸ‬ ‫ﻫﻞ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻳﺤﺪدو‬ ‫ﻋﺸﺎن‬
European guidelines generally encourage beta-blockers or calcium-channel blockers but also
emphasise that choice of agent may be affected by the patient's baseline pulse, blood pressure, and
comorbidities including systolic dysfunction
1⃣ Standard Therapy
DH-CCB ‫او‬ BB ‫ﻋﻠ‬ ‫ﻳﻤﺸ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫اﻧﻪ‬ Standard Therapy ‫ال‬
.. First step ‫ك‬
2ed Step ‫ﻟﻞ‬ ‫ﺑﻨﻠﺠﺄ‬ ‫اﻟﻤﻄﻠﻮب‬ Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬
... BB+DH-CCB ‫ال‬ ‫ﺑﻴﻦ‬ Combination ‫اﻋﻄﺎء‬ ‫وﻫ‬
LAN ‫ال‬ ‫زي‬ 2ed line agent ‫ﺑﻨﻀﻴﻒ‬ Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬
Trimetazidine ‫او‬ Nicorandil ‫ال‬ ‫او‬ Ranolazine ‫اﺿﺎﻓﺔ‬ step ‫وآﺧﺮ‬
(2⃣ In pt with High heart Rate ( HR>80beat/min
non dihydropyridine CCB ‫او‬ BB ‫ﻧﻌﻄ‬ 1st step ‫ال‬
Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬
NDH-CCB ‫وال‬ BB ‫ال‬ ‫ﺑﻴﻦ‬ Combination ‫اﻋﻄﺎء‬ 2ed step ‫ال‬
Close Monitoring ‫ﻣﻊ‬ Lowest Dose ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﺑﺸﺮط‬
Ivabradine ‫وال‬ BB ‫ال‬ ‫ﺑﻴﻦ‬ Combination ‫ﻧﻌﻤﻞ‬ 3ed step ‫ال‬

38. ...NDH-CCB ‫وال‬ Ivabradine ‫ال‬ ‫ﺑﻴﻦ‬ Combine ‫ﻋﻤﻞ‬ ‫وﻣﻤﻨﻮع‬ ⛔⛔
CYP3A4 ‫ال‬ ‫ﺑﻴﺜﺒﻄﻮ‬ Diltiazem ‫وال‬ Verapamil ‫ال‬
CYP3A4 Inhibitors (Moderate) may increase the serum concentration of Ivabradine
‫ﻟﻞ‬ Risk ‫ب‬ ‫اﻟﻤﺮﻳﺾ‬ ‫وﺑﻴﺪﺧﻞ‬
bradycardia
prolonged QTc interval
.transient episodes of torsades de pointes
‫اﻟﺘﺎﻟﻴﺔ‬ ‫اﻻدوﻳﺔ‬ ‫ﻣﻦ‬ ‫واﺣﺪ‬ ‫ﻧﻀﻴﻒ‬ Step ‫وآﺧﺮ‬
Nicorandil/ Ranolazine /Trimetazidine
3⃣In pt whoes HR less than 50 beat/min
DH-CCB ‫ال‬ ‫ﻫﻮ‬ 1st step ‫ال‬
‫زﺑﻂ‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬
LAN ‫ال‬ ‫ﻋﻠ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﺑﻴﺘﺸﻔﺖ‬
LAN ‫وال‬ DH-CCB ‫ال‬ ‫ﺑﻴﻦ‬ combine ‫ﺑﻨﻌﻤﻞ‬ Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬
‫اﻟﺘﺎﻟﻴﺔ‬ ‫اﻻدوﻳﺔ‬ ‫ﻣﻦ‬ ‫واﺣﺪ‬ ‫ﻧﻀﻴﻒ‬ line ‫وآﺧﺮ‬
Nicorandil/ Ranolazine /Trimetazidine
4⃣ In pt with Heart failure or LV Dysfunction
BB ‫ال‬ ‫ﻫ‬ 1st step ‫ال‬
LAN ‫ال‬ ‫ﻣﻊ‬ ‫او‬ Ivabradine ‫ال‬ ‫ﻣﻊ‬BB ‫ال‬ 2ed step ‫ال‬
⬇ ‫ﻣﻦ‬ ‫واﺣﺪ‬ ‫ﻧﻀﻴﻒ‬ 3ed step ‫ال‬
Nicorandil/ Ranolazine /Trimetazidine
5⃣In pt with Low Bp
Low dose NDH-CCB ‫او‬ Low dose BB ‫ال‬ ‫ﻫﻮ‬ 1st step ‫ال‬
⬇ ‫اﻟﺘﺎﻟﻴﺔ‬ ‫اﻻدوﻳﺔ‬ ‫ﻣﻦ‬ ‫واﺣﺪ‬ ‫ﻧﺴﺘﺨﺪم‬ 2ed step ‫ال‬
Ivabradibe /Ranolazine /Trimetazidine
.... Combination ‫ﻧﻌﻤﻞ‬ 3ed step ‫ال‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

45. Cardiology_70 #Ischemic_heart_disease_12#
.... Anti-Ischemia ‫ك‬ ‫ﺑﻴﺸﺘﻐﻠﻮ‬ Nicorandil ‫وال‬ Trimetazidine ‫ال‬ ‫ﻛﻴﻒ‬
... ‫ﻓﻴﻬﻢ‬ ‫واﺣﺪ‬ ‫ﻟﻮاﺣﺪ‬ ‫واﻟﺠﺮﻋﺎت‬ ‫ﺎﻧﺰم‬‫اﻟﻤﻴ‬ ‫ﻧﺸﻮف‬
Trimetazidine
‫أﻛﺴﺪة‬ ‫ﻣﻦ‬ %35 ‫و‬ (Free Fatty Acid (FFA‫ال‬ ‫أﻛﺴﺪة‬ ‫ﻣﻦ‬ ‫ﻧﺎﺗﺞ‬ ‫ﻮن‬‫ﻫﻴ‬ ‫اﻟﻘﻠﺐ‬ ‫ﺑﻴﺤﺘﺎﺟﻪ‬ ‫اﻟﻠ‬ ATP ‫ال‬ ‫ﻣﻦ‬ %60 ‫اﻟﻄﺒﻴﻌ‬ ‫ﺑﺎﻟﻮﺿﻊ‬
.. ‫ﻮز‬‫اﻟﺠﻠ‬
‫اﻷوﻛﺴﺠﻴﻦ‬ ‫ﻣﻦ‬ ‫ﻛﺒﻴﺮة‬ ‫ﻛﻤﻴﺔ‬ ‫ﺑﻴﺤﺘﺎج‬ FFA ‫ال‬ ‫ﻳﺄﻛﺴﺪ‬ ‫ﻋﺸﺎن‬ Cardiac Tissue ‫ال‬
Cardiac tissue ‫ﻟﻞ‬ ‫ﻛﻮﻳﺲ‬ ‫واﺻﻞ‬ ‫ﻣﺶ‬ ‫اﻟﺪم‬ Angina ‫ال‬ ‫ﻣﺮﻳﺾ‬
FFA ‫ال‬ ‫ﻟﺤﺮق‬ O2 ‫ال‬ ‫ﻣﻦ‬ ‫ﻛﺎﻓﻴﻪ‬ ‫ﻛﻤﻴﺔ‬ ‫ﻓ‬ ‫ﻣﺎ‬ ‫ﺑﺎﻟﺘﺎﻟ‬
Cell ‫ال‬ ‫داﺧﻞ‬ FFA ‫ال‬ ‫ﻓﺒﺘﺘﺮاﻛﻢ‬
PH of cardiac cell ‫ال‬ ‫ﻫﺘﻐﻴﺮ‬ ‫ﻳﻌﻨ‬ fatty acid ‫اﺳﻤﻬﺎ‬ ‫وﻣﻦ‬
Acidosis ‫وﻫﺘﻌﻤﻞ‬
... MI ‫ب‬ ‫اﻟﻤﺮﻳﺾ‬ ‫وﻳﺪﺧﻞ‬ Contraction ‫ال‬ ‫ﻓﻬﻴﺰود‬ sarcoplasmic reticulum ‫ال‬ ‫ﻣﻦ‬ Ca ‫ال‬ ‫اﻓﺮاز‬ ‫ﺑﻴﺤﻔﺰ‬ Acidosis ‫ال‬
‫ﻓﻘﻂ‬ Carbohydrate ‫ال‬ ‫ﺑﺪﺧﻮل‬ ‫وﺗﺴﻤﺢ‬ Cardiac tissue ‫ﻟﻞ‬ FFA ‫ال‬ ‫دﺧﻮل‬ ‫ﺗﻤﻨﻊ‬ ‫أدوﻳﺔ‬ ‫ﻻﺧﺘﺮاع‬ ‫اﻟﺘﻮﺟﻪ‬ ‫ﻓﺼﺎر‬
ATP ‫ال‬ ‫اﻧﺘﺎج‬ ‫ﻓ‬ carbohydrate‫ال‬ ‫ع‬ ‫ﻳﻌﺘﻤﺪ‬ ‫ﻫﻴﺼﻴﺮ‬ FFA ‫ع‬ ‫ﺑﻴﻌﺘﻤﺪ‬ ‫اﻟﻘﻠﺐ‬ ‫ﻣﺎ‬ ‫ﻓﺒﺪل‬ Metabolic switch ‫ﻫﻴﺼﻴﺮ‬ ‫ﻳﻌﻨ‬
.. ‫اﻟﻘﻠﺐ‬ ‫ﺧﺼﺎﺋﺺ‬ ‫وﻻ‬ Heart Rate ‫ال‬ ‫ﻳﺘﺄﺛﺮ‬ ‫ﻣﺎ‬ ‫ﺑﺪون‬
PFOX Drug ‫ب‬ ‫اﺗﺴﻤﺖ‬ ‫اﻷدوﻳﺔ‬ ‫وﻫﺎي‬
PFOX: Prevent Fatty Acid Oxidation
Trimetazidine : ‫ال‬ ‫ﻫﻮ‬ ‫ﻋﻠﻴﻬﺎ‬ ‫ﻣﺜﺎل‬ ‫واﺷﻬﺮ‬
Trimetazidine exerts antianginal and anti-ischemic effects by altering metabolism to maintain
intracellular ATP levels in ischemic regions without changing hemodynamic parameters. One direct
mechanism proposed is the inhibition of long-chain 3-ketoacyl-CoA thiolase (3-KAT, the final enzyme
responsible for fatty acid β-oxidation), with the effect of potentiating glucose oxidation, leading to
more efficient ATP production with less oxygen demand however, another study suggests
therapeutic benefits are not derived from inhibition of 3-KAT
Trimetazidine ‫ال‬ ‫ﺟﺮﻋﺔ‬
Chronic stable angina (adjunctive): Oral:
Immediate-release tablet: 20 mg 3 times daily.
Modified-release tablet: 35 mg twice daily.
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Nicorandil
Anti-Ischemia ‫ك‬ ‫ﻓﻴﻬﻢ‬ ‫ﺑﺸﺘﻐﻞ‬ ‫ﻃﺮﻳﻘﺘﻴﻦ‬ ‫اﻟﻪ‬ Nicorandil ‫ال‬
Hyperpolarization ‫ﺑﻴﺤﺼﻞ‬ ‫وﺑﺎﻟﺘﺎﻟ‬ ‫اﻟﺨﻼﻳﺎ‬ ‫داﺧﻞ‬ ‫ﻣﻦ‬ +k ‫ال‬ ‫ﻓﺒﻴﻄﻠﻊ‬ Cardiac tissue ‫ﺑﺎل‬ ‫اﻟﺒﻮﺗﺎﺳﻴﻮم‬ ‫ﻗﻨﻮات‬ ‫ﺑﻴﻔﺘﺢ‬1⃣
Cardiac tissue ‫ﻟﻞ‬ Relaxation ‫و‬

46. Potassium channel activator; dilates arterial muscle reducing afterload with no effect on myocardial
contractility.
V.D ‫ﻓﺒﻴﻌﻤﻞ‬ Nitric Oxide ‫ﺑﻴﻄﻠﻊ‬ 2⃣
.Vasodilation properties (due to nitrate moiety) which reduces preload
‫ال‬ ‫ﻣﻊ‬ ‫ﻳﻨﻌﻄ‬ ‫ﻣﻤﻨﻮع‬ ‫اﻟﻨﻴﺘﺮات‬ ‫أدوﻳﻮ‬ ‫زي‬ ‫زﻳﻪ‬ Nicorandil ‫ال‬
( PDE5 Inhibitor ( Avanafil / Mirodenafil/ Sildenafil/ Tadalafil / Udenafil/Vardenafil
: ‫ﺟﺮﻋﺘﻪ‬
Chronic stable angina: Oral: Note: Usual dosage and frequency varies by region/country.
Ikorel (Australia/United Kingdom labeling): Initial: 5 to 10 mg twice daily (morning and evening);
based on response and tolerability may increase to target dose of 10 to 20 mg twice daily.
Use a lower starting dose of 5 mg twice daily if headache or other adverse effects occur (maximum:
40 mg twice daily).
.Sigmart (Korean labeling): Usual: 5 mg 3 times daily; may adjust dose according to response
❤. ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

49. Cardiology_71 #Ischemic_heart_disease_13#
European Society of Cardiology ESC Management
Guideline for Stable Angina part 2...
( Drug Used in Event Prevention ( Aspirin , Lipid Lowering drug
strong ‫وﻛﺎﻧﺖ‬ Baby aspirin ‫ع‬ ‫ﻫﻴﻤﺸ‬ Stable Angina ‫ﻣﺮﻳﺾ‬ ‫أي‬ ‫ان‬ American Guideline ‫ﺑﺎل‬ ً‫ﺎ‬‫ﺳﺎﺑﻘ‬ ‫ﺷﻔﻨﺎ‬
... recommendation
: ‫ﻟﻼﺳﺒﺮﻳﻦ‬ Recommendation ‫اﺗﻨﻴﻦ‬ ‫ﻓﻔ‬ European ‫ال‬ ‫ﺣﺴﺐ‬ ‫اﻣﺎ‬
( Strong Recommendation (class 1 level A
‫اﺳﺒﺮﻳﻦ‬ ‫ع‬ ‫ﻓﻴﻤﺸ‬ Revascularization ‫ﻋﻤﻞ‬ ‫او‬ MI ‫ل‬ ‫ﻫﻴﻚ‬ ‫ﻗﺒﻞ‬ ‫وﺗﻌﺮض‬ Stable Ischemic Heart disease ‫ﻣﺮﻳﺾ‬ ‫أي‬
( Weak Recommendation (class 2b level C
prior MI ‫ﻋﻨﺪه‬ ‫ﻣﺎ‬ ‫او‬ revascularization ‫ﻋﺎﻣﻞ‬ ‫ﻛﺎن‬ ‫ﻣﺎ‬ ‫ﻟﻮ‬ ‫ﺣﺘ‬ ‫اﺳﺒﺮﻳﻦ‬ ‫ع‬ SIHD ‫ال‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻳﻤﺸ‬ ‫ﻦ‬‫ﻣﻤ‬ ‫اﻧﻪ‬
European guidelines make a less strong recommendation for patients with SIHD without prior
infarction or revascularisation in using Aspirin
.. Clopidogrel ‫ﻫﻮ‬ ‫ﻓﺎﻟﺒﺪﻳﻞ‬ ‫اﻻﺳﺒﺮﻳﻦ‬ ‫اﺳﺘﺨﺪام‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
American ‫وال‬ European ‫ال‬ ‫ﺑﻴﻦ‬ ‫اﺧﺘﻼف‬ ‫ﻛﻤﺎن‬ ‫ﻓ‬
(Dual Antiplatlet Therapy (DAPT ‫ال‬ ‫ﻧﺴﺘﺨﺪم‬ ‫ﻣﺘ‬ ‫ﻓ‬
SIHD ... ‫ﻣﺮﻳﺾ‬ ‫ﻓ‬
American : In patients with SIHD without prior history of ACS, coronary stent implantation, or
recent (within 12 months) CABG, treatment with DAPT is not beneficial...(Harmful)
European : Adding a second antithrombotic drug to aspirin for long-term secondary prevention
should be considered in patients with high-risk of ischaemia events and without high bleeding risk.. (
(class 2a,A
... DAPT ‫ع‬ ‫ﻳﻤﺸ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻔﻀﻞ‬‫ﻳ‬ low bleeding risk ‫و‬ high Ischemia risk ‫ﻋﻨﺪه‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬ European ‫ال‬ ‫ﻓﺤﺴﺐ‬
High Ischemia Risk ⬇⬇ ‫ﻋﻨﺪه‬ ‫اﻟﻠ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻣﻴﻦ‬
'Diffuse multivessel CAD with at least one of the following: diabetes mellitus requiring medication,
.recurrent MI, PAD, or CKD with eGFR 15-59 mL/min/1.73 m²
High bleeding Risk ⬇⬇.. ‫ﻋﻨﺪه‬ ‫اﻟﻠ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫اﻣﺎ‬
Prior history of intracerebral haemorrhage or ischaemic stroke, history of other intracranial
pathology, recent gastrointestinal bleeding or anaemia due to possible gastrointestinal blood loss,

50. other gastrointestinal pathology associated with increased bleeding risk, liver failure, bleeding
diathesis or coagulopathy, extreme old age or frailty, renal failure requiring dialysis or with 9GFR <
.15 mL/min/1.73 m²
❤‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#

52. Cardiology_72 #Ischemic_heart_disease_14#
Stable Angina ‫ال‬ ‫ﻓ‬ ‫ﺑﻮﺳﺖ‬ ‫آﺧﺮ‬
PCSK9 Inhibitor ‫ال‬ ‫ﻣﺠﻤﻮﻋﻪ‬ ‫ذﻛﺮت‬ European guideline ‫ال‬
‫اﻟﻤﺠﻤﻮﻋﺔ‬ ‫ﻫﺎي‬ ‫أﻣﺜﻠﺔ‬ ‫وﻣﻦ‬ Lipid Lowering Agent ‫ك‬
alirocumab and evolocumab
‫؟؟‬ ‫ﺑﺘﺸﺘﻐﻞ‬ ‫وﻛﻴﻒ‬ ‫اﻟﻤﺠﻤﻮﻋﻪ‬ ‫ﻟﻬﺎي‬ ‫ﺑﻨﻠﺠﺄ‬ ‫ﻣﺘ‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Statin ‫ﻋﻠ‬ ً‫ﺔ‬‫ﺑﺪاﻳ‬ ‫ﻫﻴﻤﺸ‬ SIHD ‫ال‬ ‫ﻣﺮﻳﺾ‬ ESC ‫ال‬ ‫ﺣﺴﺐ‬
Statins are the mainstay of lipid pharmacotherapy and appropriate for all patients with SIHD (unless
clearly contraindicated).
High-intensity statin therapy is indicated for most patients
‫ﻋﺎﻟ‬ LDL level ‫ال‬ ‫وﻟﺴﻪ‬ Max tolerated dose ‫ﺑﺎل‬ Statin ‫ع‬ ‫ﻣﺸ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻓﺮﺿﺎ‬ ‫ﻃﻴﺐ‬
ezetimibe ‫وال‬ Statin ‫ال‬ ‫ﺑﻴﻦ‬ Combination ‫ﺑﻨﻌﻤﻞ‬ ‫ﺑﻬﻠﺤﺎﻟﺔ‬
statin ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻳﻤﻨﻊ‬ ‫ﻣﺎ‬ ‫ﻋﻨﺪه‬ ‫اﻟﺒﺪاﻳﺔ‬ ‫ﻣﻦ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫وﻟﻮ‬
Monotherapy ‫ك‬ ezetimibe ‫ال‬ ‫ﻓﺒﻴﺴﺘﺨﺪم‬
ezetimibe10 mg orally once daily
When patients develop possible adverse effects to statin , such as myalgias, every effort should be
undertaken to ascertain whether these are actually related to the medication. Alternative statins,
lower doses, or alternative dosing schedules may be tried. For patients with contraindications or
true intolerance of high-potency statin therapy, lower doses or alternate dosing schedules may be
appropriate
ezetimibe ‫ﺑﻨﻀﻴﻔﻠﻪ‬ ‫ﺑﺮدو‬ High Risk ‫اﻟﻤﺮﻳﺾ‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬
For patients with SIHD who are at high risk and whose low-density lipoprotein cholesterol remains
high (above 1.81 mmol/L [70 mg/dL] in US guidelines, 1.42 mmol/L [55 mg/dL] in European
.guidelines), ezetimibe may be added
ezetimibe ‫ال‬ ‫ﻫﻴﺴﺘﺨﺪم‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﺣﺎﻻت‬ ‫ﺗﻼت‬ ‫ﻋﻨﺎ‬ ‫ﻓ‬ ‫ﻳﺒﻘ‬
‫ﻛﺎﻓ‬ ‫ﻣﺶ‬ ‫ﻟﻮﺣﺪه‬ Statin ‫ال‬ ‫ﻟﻮ‬، statin ‫ال‬ ‫ﻣﻊ‬ Combination ‫ك‬ 1⃣
‫ﻣﻤﻨﻮع‬ Statin ‫ال‬ ‫اﺳﺘﺨﺪام‬ ‫ﻛﺎن‬ ‫ﻟﻮ‬ ‫ﻟﻮﺣﺪه‬ ezetimibe ‫ال‬ ‫ﻧﺴﺘﺨﺪم‬ 2⃣
High Risk pt ‫ال‬ ‫ﺣﺎﻟﺔ‬ ‫ﻓ‬ Statin ‫ال‬ ‫ﻣﻊ‬ combination ‫ك‬ 3⃣
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Response ‫ﻟﻞ‬ ‫وﺻﻞ‬ ‫وﻣﺎ‬ ezetimibe ‫و‬ statin ‫ع‬ ‫ﻣﺸ‬ ‫اﻟﻤﺮﻳﺾ‬ ‫ﻟﻮ‬
PCSK9 Inhibitor ‫ال‬ ‫ﻟﻤﺠﻤﻮﻋﺔ‬ ‫ﺑﻨﻠﺠﺄ‬ ‫ﺑﻬﻠﺤﺎﻟﺔ‬
For patients with SIHD who are at very high risk and whose low-density lipoprotein cholesterol

53. remains high (above 1.81 mmol/L [70 mg/dL] in US guidelines, 1.42 mmol/L [55 mg/dL] in European
guidelines), a PCSK9 inhibitor may be added to maximal statin and ezetimibe therapy
: ‫ﻛﺎﻟﺘﺎﻟ‬ ‫اﻟﻤﺠﻤﻮﻋﻪ‬ ‫ﻫﺎدي‬ ‫ﺷﻐﻞ‬ ‫ﺮة‬‫ﻓ‬
LDL -Receptor ‫اﺳﻤﻪ‬ liver ‫ال‬ ‫ﻋﻠ‬ Receptor ‫ﻋﻨﺎ‬ ‫ﻓ‬
‫ﺒﺪ‬‫اﻟ‬ ‫ﺑﺨﻼﻳﺎ‬ ‫ﺴﺮه‬‫وﻳ‬ ‫اﻟﺪم‬ ‫ﻣﻦ‬ LDL ‫ﻟﻞ‬ Reuptake ‫ﻳﻌﻤﻞ‬ ‫وﻇﻴﻔﺘﻪ‬
‫اﻓﻀﻞ‬ ‫ﻛﺎن‬ ‫ﻣﺎ‬ ‫ﻛﻞ‬ Liver ‫ال‬ ‫ع‬ ‫اﻛﺘﺮ‬ LDL Receptor ‫ﻓ‬ ‫ﻛﺎن‬ ‫ﻣﺎ‬ ‫ﻛﻞ‬
... Atherosclerosis ‫ال‬ ‫ﻣﻨﻌﻨﺎ‬ ‫وﺑﺎﻟﺘﺎﻟ‬ ‫ﺑﺎﻟﺪم‬ LDL ‫ال‬ ‫ﻣﺴﺘﻮى‬ ‫ﻗﻞ‬ ‫ﻣﺎ‬ ‫وﻛﻞ‬
‫اﻟﺒﺮوﺗﻴﻦ‬ ‫ﻫﺎد‬ PCSK9 ‫اﺳﻤﻪ‬ ‫ﺑﺎﻟﺠﺴﻢ‬ ‫ﺑﺮوﺗﻴﻦ‬ ‫ﻓ‬ ‫اﻧﻪ‬ ‫وﺟﺪو‬
LDL- Receptor ‫ﻟﻞ‬ Lysis ‫ﺗﻌﻤﻞ‬ ‫اﻧﻬﺎ‬ ‫ﺒﺪ‬‫اﻟ‬ ‫ﺧﻼﻳﺎ‬ ‫ﺑﻴﺤﻔﺰ‬
LDL Reuptake ‫ال‬ ‫وﺑﻴﻘﻞ‬ LDL-Receptor ‫ال‬ ‫ﺑﻴﻘﻞ‬ ‫ﺑﺎﻟﺘﺎﻟ‬
‫وﺑﺎﻟﺸﺮاﻳﻴﻦ‬ ‫ﺑﺎﻟﺪم‬ LDL ‫ال‬ ‫ﻓﺒﻴﺘﺮاﻛﻢ‬
‫وﺗﺜﺒﻄﻪ‬ PCSK9 protein ‫ﺑﺎل‬ ‫ﺗﻤﺴﻚ‬ ‫ادوﻳﻪ‬ ‫ﻓﺎﺧﺘﺮﻋﻮ‬
PCSK9 ‫ال‬ ‫ﺑﻴﺜﺒﻄﻮ‬ Monoclonal antibody ‫ال‬ ‫ﻓﺼﻴﻠﺔ‬ ‫ﻣﻦ‬ ‫دواﺋﻴﻦ‬ ‫ﻋﻨﺎ‬ ‫ﻓﻔ‬
alirocumab75-150 mg subcutaneously every 2 weeks; or 300 mg subcutaneously once monthly
evolocumab140 mg subcutaneously every 2 weeks; or 420 mg subcutaneously once monthly
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#