This document provides a summary of angina pectoris (chest pain). It begins with an example case history and treatment. It then defines angina and describes the main types (stable and unstable). It discusses the pathophysiology and clinical presentation. It outlines the diagnostic tests and procedures used to diagnose angina. The goals and approaches to treatment are summarized, including drug therapies like nitrates, beta blockers, and calcium channel blockers. Other measures for managing coronary artery disease are mentioned like lifestyle changes and procedures.

2. King Faisal University College of Clinical Pharmacy

3. Angina Pectoris By Taher Haddad

4. No interruption Speaking during the presentation (NOT ALLOWED) Note down your comments & questions There will be time for comments & questions Before Getting Started Think & act scientifically

5. 1- Case History with Treatment 2- Definition (what is angina?) 3- Types of Angina 4- Pathophysiology 5- Clinical Presentation 6- Diagnosis (with Tests and Procedures) 7- Goals of Treatment 8- Drug Therapy and Other Measures Outlines

6. Case History An 80 years old saudi female, non-smoker, D.M. HTN, dyslipidemic, with no previous chest pain, presented with severe shortness of breath & chest tightness. Condition started about 1 month ago, gradually: cough & expectoration of whitish sputum (no hemoptysis). One day before admission she's severly dyspnic & distressed. Drug history only NSAIDs. On ICCU admission: fully conscious & oriented. From a patient file in king Saud Medical Complex, Riyadh

7. Result indicated that she had angina, and according to that result, she started receiving the following regimen: Carvidelol 12.5 BID Capoten 12.5 BID ASA 81 mg OD Atorva 500 mg BID Omeprazole 20 mg OD Iron 200 mg BID Multivitamin OD Syp lactoluse 15 ml PO Treatment for The Case From a patient file in king Saud Medical Complex, Riyadh

8. Definition Angina is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. It is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. Type of chest pain: pressure or discomfort Medscape.com, Jamshid Alaeddini & Jamshid Shirani

9. ADAM.COM

10. Types of Angina Angina is classified broadly as stable or unstable , depending on its pattern of occurrence and severity. medmovie.com

11. Stable angina occurs when increased physical activity (e.g., hurrying across a street or climbing a long stairs) which creates a greater demand for oxygen-rich blood to reach heart tissue. Unstable angina occurs with lesser degrees of exertion or while at rest. Unstable angina that occurs at rest is the most serious form. This type usually is caused by the formation of a blood clot at the site of a ruptured plaque in a coronary artery. Types of Angina (cont.) Healthcommunities.com (cardiologychannel) 2009

12. Pathophysiology Myocardial ischemia develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand. This causes myocardial cells to switch from aerobic to anaerobic metabolism, with a progressive impairment of metabolic, mechanical, and electrical functions. Studies have shown that adenosine may be the main chemical mediator of anginal pain. During ischemia, ATP is degraded to adenosine, which, after diffusion to the extracellular space, causes arteriolar dilation and anginal pain. Medscape.com, Jamshid Alaeddini & Jamshid Shirani

13. Clinical Presentation Angina is a symptom of ischemic heart disease (IHD). Episodes of stable angina typically are brought on by exertion or emotion and are relieved with rest. An attack of stable angina lasts from 1 to 5 minutes and is described as - squeezing, - choking, - smothering, or - crushing pressure in the chest. Angina pain may radiate to the shoulders, arms, back, neck, or jaw. Patients with atherosclerosis also may experience sweating, clamminess, shortness of breath (dyspnea). Healthcommunities.com (cardiologychannel) 2009

14. Clinical Presentation (cont.) © Reed Group Medical Disability Advisor, mdguidelines.com New York Heart Associates, nyheart.net

15. Unstable angina causes symptoms that are more severe, more frequent, and occur with modestly increased physical activity and at rest. Blood clots may form at anytime and may partially dissolve spontaneously. Whenever this occurs, blood flow to heart tissue is blocked and angina occurs. An attack of unstable angina may last several minutes to half an hour or longer. Unstable angina is an acute coronary syndrome, which is a medical emergency that requires immediate attention. Clinical Presentation (cont.) Healthcommunities.com (cardiologychannel) 2009

16. Diagnosis A diagnosis of stable angina is based primarily on symptoms, such as chest pain. A diagnosis of unstable angina is made when there is - new onset angina that is severe and/or frequent; - chronic stable angina who develop more frequent, severe, prolonged, or more easily triggered episodes; - angina at rest. Healthcommunities.com (cardiologychannel) 2009

17. Diagnostic Tests and Procedures 1- ECG (Electrocardiogram) It detects and records the electrical activity of the heart. Certain electrical patterns that the ECG detects can suggest whether CAD is likely. However, some people with angina have a normal ECG. The ECG is usually normal between attacks. During an attack there may be a transient ST segment depression. If the angina is provoked by exertion, an exercise stress ECG should be performed. National heart, lung and blood institute General practice notebook (a U K medical reference on the world wide web)

18. Diagnostic Tests and Procedures Butterworth Publishers

19. 2- Stress ECG Testing Typically, this test involves taking an electrocardiogram (ECG) before, during, and after exercise on a treadmill or stationary bicycle. Patients who are at risk for a coronary event with exercise are, instead, given a drug to increase the heart rate. Diagnostic Tests and Procedures Healthcommunities.com (cardiologychannel) 2009 National heart, lung and blood institute

20. 3- Coronary angiogram Is obtained by injecting contrast material into the bloodstream and taking x-rays of the coronary arteries. This enables the physician to see blockages, malformations, and stenosis in the vessels. 4- Blood Tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in blood. Abnormal levels may indicate risk factors for CAD. Some studies suggest that high levels of CRP (C-reactive protein) in the blood may increase the risk for CAD and heart attack. Diagnostic Tests and Procedures Healthcommunities.com (cardiologychannel) 2009 National heart, lung and blood institute

21. Goals of Treatment All treatments for people with coronary artery disease have the same goals: - to decrease the effects of the disease on the quality of life and alleviate symptoms. - to reduce mortality due to CAD progression. Patient information — Angina treatment , UpToDate.com (Patient Preview)

22. Drug Therapy Currently, there are three main types of drugs used: 1) Nitrates 2) Beta blockers 3) Calcium channel blockers Nitrates or beta blockers are usually preferred for initial treatment of angina, and calcium channel blockers may be added if needed. Patient information — Angina treatment , UpToDate.com (Patient Preview)

23. Drug Therapy (cont.) 1) Nitrates Nitrates improve blood flow by relaxing and dilating veins and arteries, including the coronary arteries. Examples: nitroglycerin and isosorbide dinitrate. Side effects: The most common side effects of nitrates are headache, lightheadedness, flushing, and an increase in heart rate. Patient information — Angina treatment , UpToDate.com (Patient Preview)

24. Drug Therapy (cont.) 2) Beta blockers Beta blockers reduce the heart rate, blood pressure, and the force of contractions, thereby decreasing the amount of oxygen the heart requires to pump blood. Examples: atenolol, metoprolol, nadolol and propranolol. Side effects: Cardiac effects -- worsen heart failure, bradycardia Noncardiac effects -- constriction of airways, circulatory problems, Impotence, hallucinations, insomnia, and fatigue Patient information — Angina treatment , UpToDate.com (Patient Preview)

25. 3) Calcium channel blockers Calcium channel blockers dilate arteries and lower blood pressure, which decreases the force of contractions. They also dilate veins, reducing the amount of blood returning to the heart, which reduces the workload of the heart. Examples: amlodipine, nifedipine, nicardipine, verapamil and diltiazem. Side effects: flushing, dizziness and lightheadedness, headache, peripheral edema and depression of cardiac function (with non-dihydropyridines) Drug Therapy (cont.) Patient information — Angina treatment , UpToDate.com (Patient Preview)

26. Other Measures in Managing CAD Anticoagulants Aspirin: (it helps to prevent blood clotting, keeping the narrowed arteries open and lowering the risk of a heart attack). Treat high blood pressure Treat high cholesterol Quit smoking Lose excess weight Reduce stress Exercise regularly Patient information — Angina treatment , UpToDate.com (Patient Preview)

27. Other Treatment Options Percutaneous Coronary Intervention (previously called Angioplasty or Balloon Angioplasty) CABG (Coronary Artery Bypass Graft Surgery) 2009 American Heart Association website

28. References Patients files from King Saud Medical Complex. Medscape.com, Jamshid Alaeddini & Jamshid Shirani ADAM.COM medmovie.com Healthcommunities.com (cardiologychannel) 2009 National heart, lung and blood institute General practice notebook (a U K medical reference on the world wide web) Butterworth Publishers Patient information — Angina treatment , UpToDate.com (Patient Preview) Medical Disability Advisor, mdguidelines.com New York Heart Associates, nyheart.net American Heart Association website

30. Hospital Training King Saud Medical Complex (Riyadh)

31. Problems from my view The program there is unfit able with our training period (6 weeks) , it needs at least 4 months!! The program also not matching our training goals & plan, it was all clinical & I think in this training we should be in the pharmacy learning the basic concepts of WHAT WE CALL IT PHARMACIST.. It was higher than our knowledge & skills No one from the college told us about the situation there & we were surprised when Dr. Y. Alo’mi said: every student will go into two department only! (3 weeks for the 1 st & 3 for the other one)

32. Comments & Questions

33. THE END THANK YOU