1. 1

2.  Chest pain caused by transient myocardial
ischemia due to an imbalance between
 Myocardial oxygen supply
 Myocardial oxygen demand
2

3. 3
Angina
Stable Unstable Prinzmetal

4.  Stable angina:
 Most common type of angina
 Common in smokers, hypertensive patients
4

5.  Unstable angina:
 Less common than stable angina
 can occur at any time, during
○ strenuous exercise
○ Rest
 Urgent condition and can progress to
heart attack
5

6.  Prinzmetal Angina
 vasospasm occurs
○ Narrowing of the coronaries
○ No buildup of fatty deposits in the artery walls
 Experienced at night, which can be
disruptive to sleep
6

7. 7
 Coronaries narrow
by plaque lead to
stable angina
 Clot formation
lead to
unstable angina
Video

8. 8
 videoWhat Causes Angina -
presentation.wmv

9.  The common symptoms:
 Chest pain
 Squeezing of the chest
 Uncomfortable pressure
9

10.  Chest pain that may spread to :
○ Left shoulders
○ Neck
○ Arms
○ Jaws
 The pain is milder when leaning forward
10

11.  Major non-modifiable
 Age over 40
 Gender (♂ > ♀ )
 Family history
 Major modifiable
 Dyslipidaemia
 Hypertension
 Smoking
 DM
(insulin resistance) 11

12.  Major non-modifiable
 Age over 40
 Gender (♂ > ♀ )
 Family history
 Major modifiable
 Obesity
 Sedentary lifestyle
 Atherogenic diet
12

13.  Minor Controllable
○ Lack of exercise
○ Personality
○ Extreme temperatures
○ Emotional Stress
○ Alcohol Abuse
13

14.  ≥ 3 CAD risk factors
(↑cholesterol, DM , smoking , HTN).
 Prior CAD (cath stenosis ≥ 50%).
 ≥ 2 anginal events----- ≤ 24 hours.
 ST segment deviation.
14

15.  ECG ------ non-invasive (85% accurate).
 Exercise stress test with ECG .
 Holter monitoring (24 hrs ambulatory ECG).
 Cardiac catheterization
 Diagnostic
 Therapeutic
15

16.  Useful to confirm angina pain and other
abnormal features.
 Must be coupled with some
sort of stress test
 ECG levels during a 24 hour period
(used with nocturnal angina)
16

17. 17

18.  Insertion of a catheter to coronaries
 Dye is injected
 Detect blocks
 Accurate
 Effective
18

19. 19
×Exclude people from treatment based
on their age.

20. 20
×Investigate/treat symptoms
differently in men and women in
different ethnic groups.

21. 21
×Offer vitamin or fish oil supplements

22. 22
×Offer TENS, EECP or acupuncture
• TENS Transcutaneous electrical nerve stimulation
• EECP Enhanced External counter pulsation

23. 23
×Routinely offer drugs for 2ry
prevention of CVD to people with
suspected cardiac syndrome X
Cardiac syndrome X is angina (chest pain) with
signs associated with decreased blood flow to
heart tissue but with normal coronary arteries

24. 24
Management
Risk factor
modification
Pharmacological
management Surgery

25. 25
 Limit alcohol
 No high saturated fat/high cholesterol
foods
 Maintain normal blood lipid levels
 Maintain blood pressure within normal
range

26.  Regular exercise
 Optimal weight
 Maintain blood glucose within normal
range
 No tobacco
26

27.  Pharmacological Management
include:
 Beta blockers
 calcium channel blockers
 Nitrates
27

28.  Pharmacological Management
include:
 Antiplatelets
 Other agents
28

29. 29
Beta
Blockers Selective β1
Atenolol
Acebutolol
Metoprolol
Bisoprolol

30. 30
Beta
Blockers Nonselective
Propranolol
Timolol
Nadolol

31.  Pharmacological effects:
 ↓ myocardial oxygen consumption by:
○ ↓ heart rate
○ ↓blood pressure
○ ↓ myocardial contractility
31

32. 32
Calcium
channel
blocker
(DHP) class Amlodipine
(Non DHP)
class
Diltiazem
verapamil

33.  Pharmacological effects:
Reduce trans membrane flux of calcium via
calcium channels:
 Negative chronotropic
 Negative inotropic
 Smooth Muscle relaxation
 Therefore ↓ myocardial oxygen
Consumption & Enhance coronary perfusion.
33

34. 34
Nitrates
Short acting
Nitroglycerin
Long acting
Isosorbid

35.  Pharmacological effects:
 Relax all types of smooth muscles
vascular or non vascular.
 Relax both arteries and veins but more
effective on veins.
 Increase cGMP that decrease platelet
aggregation.
35

36. 36
Antiplatelets
Aspirin Clopidogrel

37.  Pharmacological activity:
 Prevent thrombus formation by inhibiting
platelet aggregation by:
○ Inhibits prostaglandin synthesis by
cyclooxygenase
○ Inhibitor of ADP-induced pathway for
platelet aggregation
37

38.  Ranolazine
 Inhibits fatty acid oxidation
 Inhibits late sodium current into
myocardial cells
 Prolongs QT interval
38

39.  Ranolazine
 Indicated for chronic angina unresponsive to
other antianginal treatments.
 Does not reduce blood pressure or heart rate
 Therefore ↓ myocardial oxygen
Consumption and maintain perfusion
39

40.  Surgical options includes:
 CABG
 Veins from
○ Saphenous vein (leg)
 Arteries from
○ Internal mammary artery (chest)
40

41.  Surgical options inlcludes:
 PCI
o Use balloon
o Use stent
41
PCI Percutaneous coronary
intervention

42.  Angina condition can progress to
myocardial infarction MI
 MI includes permanant necrosis in the
tissue of myocardium
 Patient non responsive to NTG
 Don’t give more than 3 NTG sublingual
pills
42

43.  Emergency situation
 Quick management required:
 Systolic BP must be maintained
above 100 mm Hg and, optimally, below 140 mm Hg.
 OXYGEN
 MORPHINE (IV)
 BETA-BLOCKERS & NITRATES (IV)
 THROMBOLYTICS
43
0 hrs
0% damage
24 hrs
100% damage

44.  Angina is chest pain caused by
transient myocardial ischemia due to
lack of adequate oxygen supply
44

45. 45
Angina
Stable Unstable Prinzmetal

46.  Angina occurs due to narrowing of
the coronary arteries by:
 Spasm
 Plaque
 formation
46

47.  Angina caused by:
 Smoking
 Sedentary life
 Unhealthy foods
 Alcohol abuse
47

48.  Angina is presented mainly as:
 Chest pain that may spread to :
○ Left shoulders
○ Neck
○ Arms
○ Jaws
48

49.  Angina can be diagnosed by:
 ECG (stress)
 Coronary angiography
49

50. 50
DON’T Offer TENS, EECP or
acupuncture

51. 51
×Offer vitamin or fish oil supplements

52. 52
DON’T Routinely offer drugs for 2ry
prevention to patient with suspected
cardiac syndrome X

53. 53
Management of
angina
Risk factor
modification
Pharmacological
management Surgery

54.  Pharmacological Management
include:
 Beta blockers
 calcium channel blockers
 Nitrates
54

55.  Pharmacological Management
include:
 Antiplatelets
 Other agents (e.g. Ranolazine )
55

56.  Risk factor modification is the most
important
 No smoking
 Limit alcohol
 No high saturated fat/high cholesterol foods
 Maintain normal blood lipid levels
 Maintain blood pressure within normal range 56