Angina pectoris (AP) is chest pain or discomfort due to myocardial ischemia. There are different types of AP including stable angina brought on by exertion and relieved by rest, unstable angina of increasing frequency/severity including at rest, and Prinzmetal or variant angina caused by coronary artery spasm. Management involves modifying risk factors, medications like aspirin, beta-blockers, nitrates, calcium channel blockers, and ivabradine. Indications for procedures include uncontrolled or new angina, recent MI, or unstable angina. Percutaneous coronary intervention (PCI) via balloon angioplasty and stenting is used to open blocked vessels but has risks of restenosis and complications.

1. Angina pectoris
Domina Petric, MD

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.

3. Introduction
Pain may radiate to
one or both arms, the
neck, jaw or teeth.

4. Precipitating factors
physical exertion
emotion
cold weather
heavy meals

5. Associated symptoms
dyspnoea
nausea
sweatiness
faintness

6. Causes
atherosclerosis,
atheroma
anemia
aortic
stenosis
tachyarrhythmias
hypertrophic
cardiomyopathy
arteritis or small
vessel disease
(microvascular
angina, cardiac
syndrome x)

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.

9. Stable angina

10. Unstable angina
Plaque is ruptured.
There is platelet aggregation.
Thrombus formation!
Unopposed vasoconstriction!

11. Variant angina
No overt
plaques.
Intense
vasospasm!
Prognosis is very good.

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.

13. Image source: WIKIWAND
Tranzient ST elevation during pain in Prinzmetal´s angina.

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.

16. http://book-med.info

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

19. MANAGEMENT
II.

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.

27. Other drugs

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

29. Percutaneous transluminal
coronary angioplasty (PTCA)
PTCA involves
balloon dilatation of
the stenotic vessels.

30. Indications for PTCA

31. Benefits of PTCA
Early intervention may benefit high
risk patients presenting with non-ST
segment elevation myocardial
infarction.
Stenting reduces restenosis rates.

32. Complications of PTCA
restenosis (20-30% within 6
months)
emergency CABG (<3%)
myocardial infarction (<2%)
death (<0,5%)

33. Thrombosis prevention
Antiplatelet agents (clopidogrel) reduce the
risk of stent thrombosis.
Iv. glycoproteins IIb/IIIa inhibitors
(eptifibatide) reduce procedure-related
ischaemic events.
Drug-coated stents reduce restenosis rate,
but increase risk of late in-stent thrombosis.

34. Literature:
Oxford Handbook of Clinical Medicine.
Longmore M. Wilkinson I. B. Baldwin A.
Elizabeth W. Ninth edition.
Wikiwand
http://book-med.info