2. Introduction
Angina pectoris (AP) is due to
myocardial ischaemia.
AP presents as a central chest
tightness or heaviness.
Symptoms are brought on by
exertion and relieved by rest.
7. Types of angina
Stable angina is induced by effort, relieved
by rest.
Unstable (crescendo) angina is angina that is
of increasing frequency or severity and
occurs on minimal exertion or at rest.
Unstable angina is associated with high risk
of myocardial infarction.
8. Types of angina
Decubitus angina is precipitated by
lying flat.
Variant (Prinzmetal´s angina) is
caused by coronary artery spasm.
Prinzmetal´s angina may co-exist
with fixed stenosis.
12. Prinzmetal angina
This is due to coronary artery spasm which
can occur even in normal coronary arteries.
Pain occurs during rest rather than during
activity.
ECG: ST segment elevation.
ST segment elevation is present during pain,
but usually resolves as the pain subsides.
14. Prinzmetal angina
Treatment: calcium channel blockers
with or without long-acting nitrates.
Aspirin can aggravate the ischaemic
attacks in these patients.
Beta-blockers should be avoided
because they can increase vasospasm.
15. ECG in stable angina
It is usually normal.
There may be ST depression, flat or
inverted T waves, eventually signs
of past myocardial infarction.
17. ST depression
Planar (horizontal) or down-sloping ST
segment depression of one millimeter or
more is indicative of ischemia.
Up-sloping ST segment depression is
less specific and it is often found in
normal heart.
18. It is very important to exclude precipitating
factors during diagnostics of AP:
anaemia
diabetes
hyperlipidaemia
thyrotoxicosis
temporal arteritis
20. Modifying risk factors
smoking cessation
weight loss
moderate exercise
lowering arterial blood pressure
control of blood sugar and lipemia
21. Aspirin
Aspirin in dose 75-150 mg a
day can reduce mortality
rate by 34%. Aspirin is
contraindicated in
Prinzmetal angina.
22. Beta-blockers
Atenolol (for example) 50-100 mg a day
per os can reduce symptoms.
BB are contraindicated in asthma,
COPD, left ventricular failure,
bradycardia and coronary artery spasm
(like in variant angina).
23. Nitrates
Spray or sublingual tablets up to every half
an hour for symptoms relief.
Nitrates can be used for prophylaxis:
isosorbide mononitrate 20-40 mg per os
twice a day.
It is very important to achieve an 8 hours
nitrate free period to prevent tolerance.
24. Nitrates
Alternative for prophylaxis are slow-release
nitrates, adhesive nitrate skin patches and
buccal pills.
Common nitrates side effects are headaches
and hypotension.
Nitrates are contraindicated if blood pressure
is below 90/60 mmHg.
25. Long acting calcium antagonists
Amplodipine 10 mg/24 h
Diltiazem 90-180 mg/12 h
26. Ivabradine
Ivabradine inhibits the pacemaker current in
the SA node.
Ivabradine reduces heart rate.
It can be usefull in patents that can not take
beta blockers for some reason.
28. Indications for hospital
admission
new angina of sudden onset
recurrent angina in patients with
past myocardial infarction or CABG
angina uncontrolled by drugs
unstable angina
31. Benefits of PTCA
Early intervention may benefit high
risk patients presenting with non-ST
segment elevation myocardial
infarction.
Stenting reduces restenosis rates.