Angina pectoris is chest pain caused by an imbalance between oxygen supply and demand in the heart muscle. It is a common symptom of coronary artery disease. There are different classifications of angina including stable, unstable, and variant forms. Angina is caused by conditions that narrow the coronary arteries like atherosclerosis. Symptoms include chest pain that can radiate to the arm or jaw, brought on by exertion and relieved by rest. Diagnosis involves tests like ECG, stress testing, and angiography. Treatment focuses on lifestyle changes, medications like nitrates and beta blockers, and procedures like angioplasty if medications do not control symptoms. Unstable angina specifically involves worsening chest pain at rest and is

1. Angina Pectoris
By:DR.SAURAVPOUDEL
23rd October2016

3. Definition of Angina Pectoris
• is the result of myocardial ischemia caused by an
imbalance between myocardial blood supply and
oxygen demand.
• Angina is a common presenting symptom (typically,
chest pain) among patients with coronary artery
disease.

4. Classification Of Angina Pectoris
1. Stable angina or typical or exertional or classical
angina :induced by effort, relieved by rest.
2. Unstable angina or descendo angina :rapidly
worsening angina or angina at rest.
3. Post –infraction angina
4. Prinzmetal’s or vasospastic angina or variant, angina :
occurs without provocation,usually at rest as a result
of coronary artery spasm.
5. Nocturnal angina: angina that occurs during sleep at
night due to coronary ostial stenosis(narrowing of the
mouths of the coronary arteries as a result of
syphilitic aortitis or atherosclerosis).

5. Causes
o Coronary artery disease: due to narrowing or
spasm of coronary artery.
o Aortic stenosis
o Aortic regurgitation
o Systemic hypertension
o Severe anaemia

6. Clinical Features
1) Character of angina :
• Site : retrosternal i.e behind sternum
• Radiation : pain radiates to neck,jaw,left shoulder
& medial aspect of upper limb.
• Character :
pressing,squeezing,strangling,constricting,a band
across the chest,a heavy weight on the
chest.Patient cant pinpoint or localized the site of
pain.
• Duration : last 1-3 minutes,never less than 30
seconds and more than 15 minutes.

7. • Aggravating factors :
-exertion
-emotion
-cold
-heavy meal
-sexual activity
-anger and irritation
• Relieving factors:
-rest
-nitrates

8. 2) Breathlessness
3)History of smoking,hypertension,diabetes and
other risk factors.
a) Important risk factors:-
-smoking
-hypertension
-hyperlipidemia: xanthelsma
-obesity
-diabetes mellitus
-anaemia

9. xanthelesma

10. b) Cardiac Manifestation:
-loud second heart sound.
-Gallop rhythm
-Cardiomegaly
-Basal crackles
c)Generalized arterial disease:
-carotid bruit
-peripheral vascular disease.

11. Differential Diagnosis
• Myocardial infraction
• Pulmonary embolism
• Aortic dissection( occurs when a tear in the inner
wall of the aorta causes blood to flow between
the layers of the wall of the aorta, forcing the
layers apart)
• Esophageal spasm
• Pancreatitis
• pneumonia

12. Investigation
• General :
-complete blood count
-chest x- ray P/A view
-serum cholesterol and lipid profile
Lipid profile include :
• Serum cholesterol & triglycerides
• Very low density lipoprotien
• Low density lipoprotien
• High density lipoprotien

13. • Specific :
- Resting electrocardiogram
- May show evidence of previous myocardial infraction(Q
waves,inverted T waves)
- Typical change during acute ischemia,ST segment depression
- Stress ECG(tread mill test): ST segment depression considered as
positive.
- Isotope scanning: perfusion defect in myocardium during attack or
stress.
- Coronary angiography : gives detail information about site, extent &
nature of coronary artery disease.
- Echocardiography.

14. Tread mill test

15. Management
 General Measures:
-stop cigarette smoking
-control high blood pressure
-low cholesterol diet
-control DM
-regular exercise
-maintain ideal body weight.

16. Drug used in Angina:
1)Nitrates : sublingual nitroglycerine is used for
acute attack of angina.It is avialable in 0.5mg
tablet.it acts within 3 sec and peak action takes
place by 2 minutes.
-oral nitrate :isosorbide dinitrate 5-10 mg, 4-6hrly
or
-isosorbide mononitrate 10-20 mg, 8-12 hrly.
-Nitroglycerine injection is used when chest pain
due to angina doesnot respond to sublingual or
oral nitrate.

17. 2) Calcium channel blockers:
-Nifedipine retard 10-20 mg twice daily or
-Diltiazem 30-90 mg thrice a day or
-amlodipine 2.5-10 mg daily.
3)Beta-blockers: cardioselective B-blockers:
-atenolol 50-100 mg orally daily or
-metoprolol 200 mg daily
4)Aspirin and clopidegrol
-aspirin 50-100 mg daily or
-clopidegrol 75 mg daily

18. Unstable angina
• is that characterized by rapidly
worsening chest pain on minimal
exertion or at rest.
• Unstable Angina= ulcerated atheroma+
thrombus formation>>> reduction of
coronary blood flow caused by
thrombus>> angina at rest

19. Treatment
• Initial Medical Management:
- Bed rest
- Hospitalization in CCU
- I.V access with 5% dextrose
- ECG monitoring
- High flow oxygen inhalation
- Correction of precipitating factor such as
hypertension,arrhythmias,anaemia and
hypoxaemia.

20. • Drug Therapy
-aspirin 150-325 mg po daily or
-clopidegrol 75 mg daily
-Heparin:
• Unfractionated heparin: 60-80 units/kg bolus,followed by
14 units/kg/hr infusion for 48 hrs.
• Activated partial thromboplastin time should be measured
every 6 hour until a therapeutic level of 1.5-2 times the
control value is achieved.
• Low molecular weight heparin:
Enoxaparin 1mg/kg S.C. 12 hourly or
Dalteparin 120mg/kg S.C. 12 hrly

21. • Calcium channel blockers:
-Verapamil 80-120 mg 8 hrly orally or
-Diltiazem 60-120 mg 8 hrly or
-amlodipine or nifedipine with beta-blockers.
• Beta-blockers:
-atenolol 50-100 mg orally daily or
-metoprolol 200 mg daily

22. • If pain persists or recurs:
-infusion of intravenous nitrates
-Nitroglycerine 0.6-1.2 mg/hr. or
-isosorbide dinitrate 1-2 mg/hr.
• If medical management fails:
-coronary angiography.
-percutaneous coronary angioplasty.

24. THANK YOU
From : Dr. Saurav Poudel.
saurav7utd@hotmail.com (if any query).