Angina is chest pain caused by reduced blood flow to the heart. There are four types including stable angina triggered by exertion, unstable angina lasting over 15 minutes, microvascular angina of unknown cause, and Prinzmetal's angina caused by coronary artery spasm. Diagnosis involves ECG, stress test, imaging, and angiography. Treatment includes medications like beta blockers, nitrates, calcium channel blockers, and lifestyle changes.

1. Naga Swathi Sree Kavuri

2. 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.

3. There are 4 types of angina:
Stable angina:
Pain lasting 5-15 minutes that is relieved
by angina medication. It usually has a trigger, such as
physical exercise or exertion, anxiety or emotional
stress, cold temperatures.
Unstable angina:
Pain lasting longer than 15 minutes that
may not be fully relieved by angina medication. It may
indicate that you are having a heart attack. Unstable
angina often occurs without a specific trigger.

4. Microvascular angina:
• Also called Syndrome X
• Cause unknown
• Probably due to poor functioning of the small blood
vessels of the heart, arms and legs
• No arterial blockage
• Difficult to diagnose because it does not have
arterial blockage.

5. Prinzmetal’s angina :
• Prinzmetal’s angina is a variant form of angina
with normal coronary vessels or minimal
Atherosclerosis.
• It is probably caused by spasm of coronary artery.

6. PATHOPHYSIOLOGY:

7. SIGNS AND SYMPTOMS:
• chest pain or discomfort, often described as
squeezing pressure, fullness, tightness, or a heavy
weight in the center of the chest.
• pain or discomfort in the arms, neck, jaw, shoulder
or back
• pain similar to indigestion or heart burn.
• shortness of breath and tiredness
• nausea, sweating, and dizziness.

8. DIAGNOSIS:
• electrocardiogram (ECG)
• exercise stress test
• echocardiogram
• chest x-ray
• coronary angiography
• computerized tomography (CT) scan and magnetic
resonance imaging (MRI)

9. DRUGS:
1) Beta blockers.
2) Nitrates.
3) Calcium channel blockers.

10. ALGORITHM

11. SOAP NOTE:
Subjective Findings:
 Chest pain since 6 days.
 Increased sweating.
 Pedal edema.
Objective Findings:
 BP-160/90mmhg.
 Pulse rate – 90beats/min.
 Triglycerides-190mg/dl.
 VLDL-56mg/dl
 Total cholesterol-325mg/dl
 Serum creatinine-1.6mg/dl

12. ASSESSMENT:
DIAGNOSIS: ANGINA PECTORIS
ETIOLOGY: HTN, Smoking ,Alcohol.
DRUGS:
1) Tab. Pantoprazole 40mg OD
 Class : Antacid ( proton pump inhibitor )
 MOA : Proton pump inhibitor binds to H+/K+ exchanging ATPase
( proton pump) in gastric parietal cells , resulting in blockage of
acid secretion.
 DOSE : 40mg OD.
 ADR’S : head ache (>4%), abdominal pain (4%), facial
edema(<4%), chest pain(4%) , rash(4%),
nausea(1%),vomiting(>4%).

13.  Monitoring points:
 Severe hepatic impairment.
 May be associated with increased risk of osteoporosis.
 Daily long term use >3yrs may lead to malabsorbtion of
cyanocobalamin.
2) Tab. Aspirin (ECOSPIRIN) 150mg OD
 Class : Antiplatelet agents
 MOA: Inhibits synthesis of prostaglandin by cyclooxygenase,
Inhibits platelet aggregation has antipyretic and analgesic activity.
 DOSE: 80-500mg.
 ADR’S : angioedema, bronchospasm, CNS alteration,
dermatological problems, GI pain, ulceration, bleeding.

14.  Monitoring points:
 Should be taken with food to avoid GI effects.
 Discontinue therapy if tinnitus develops.
 Use with cautions in patients with history of peptic ulcers, gout,
hepatic disease etc…
3) Tab. Furosemide (LASIX) 20mg BD
 CLASS: Diuretics (loop)
 MOA: Inhibits reabsorption of sodium and chloride ions at
proximal and distal renal tubules and loop of henle.
 DOSE: 20-80mg.
 ADR’S: Hyperuricemia , hypokalemia ,anemia , headache, muscle
cramps , rash , nausea, glycosuria.

15.  Monitoring points:
 Use with caution in DM ,liver diseases and renal impairment.
 Monitor electrolytes.
 Risk of ototoxicity.
4) Tab. Spironolactone (ALDACTONE) 25 mg OD
 CLASS: Aldosterone antagonists , potassium sparing diuretics.

16. 6) Tab. Atorvastatin 40mg OD
 CLASS: Statins , HMG-CoA reductase inhibitors.
 MOA: HMG-CoA reductase inhibitors , inhibits rate limiting step
in cholesterol biosynthesis by competitively inhibiting the HMG –
CoA reductase.
 DOSE: 10-80mg
 ADR’S: Diarrhea , insomnia , nausea , muscle spasms myalgia
dyspepsia.
 Monitoring points:
 Increased blood sugar and glycosylated haemoglobin levels
reported with statin intake.
 Use with caution in elders risk of myopathy.
 Caution in hepatic impairement and recent stroke.

17. 7) Tab. ENALAPRIL 2.5mg OD:
 CLASS: ACE inhibitors.
 MOA: Prevents the conversion of angiotensin -1 to angiotensin-2
through the competitive inhibition of ACE , resulting in decreased
plasma angiotensin – 2 concentrations. Increased renin activity and
decreased aldosterone secretion.
 DOSE: 2.5 – 20 mg.
 ADR’S: Dizziness , hypotension , headache , chest pain , cough
rash.
 Monitoring points:
 Risk of hyperkalemia in patients with renal impairement.
 In pregnancy ( 2nd and 3rd trimesters) significant risk of fetal and
neonatal morbidty.

18.  Angioedema of face, extremities, lips, tongue may develop.
8) Inj. Lomorin 40mg :
 CLASS: Anticoagulant.
 MOA: Inactivates factor Xa and inhibits conversion of prothrombin
to thrombin.
 DOSE: 80units/kg IV bolus , continuous infusion of 18/kg/hr. or
5000units IV bolus, continuous infusion of 1300u/hr
 ADR’S: Mild pain , hemorrhage, anaphylaxis, osteoporosis .
 Monitoring points:
 May prolong PT.
 History of allergy.
 Heparin induced thrombocytopenia may occur, including thrombus
formation.

19. PLAN:
Therapy goals:
 To decrease chest pain.
 To prevent hospitalization.
 To increase the quality of life of patient.
 Patient specific goals:
 Alcohol cessation
 Smoking cessation
 To prevent renal complications
 To control underlying causes (HTN)
 To decrease cardiovascular complications due to increased lipid
levels.

20. Monitoring:
 Therapeutic monitoring:
 ECG monitoring
 Lipid level monitor
 Monitor B.P.
 Serum creatinine monitor
 Toxicity monitoring:
 Heparin - thrombocytopenia , heamorrhage -platelet count
monitoring.
 Aspirin - GI ulcers – GI bleeding monitor.
 Furosemide – hypomagnesimea , hypotension- monitor electrolytes
, b.p.

21.  Spiranolactone – hyperkalemia – monitor potassium levels
 Isosorbide dinitrate – hypotension, headache – monitor
electrolytes,b.p.
 Atorvastatin – increased liver enzymes- liver functioning tests
monitoing.
 Enalapril – hypotension , hyperkalemia – bp monitoring , potassium
level monitoring.
Points to physician :
 Daily use of isosorbide dinitrate is not needed.
 Enalapril should be given as BD.
 Heparin is effective dose is 70-100u/kg IV.

22.  Concurrent use of aspirin and enalapril may decrease the
effectiveness of enalapril.
 Use of anticoagulant and antiplatelet agents may increase the risk of
bleeding.
Points to patient:
 Low fat diet.
 Smoking cessation.
 Alcohol cessation.
 Regular exercise.
 Reduce salt intake.