Angina is chest pain caused by transient myocardial ischemia due to an imbalance between myocardial oxygen supply and demand. There are three main types of angina: stable angina which is the most common type, unstable angina which can occur at any time and is considered an urgent condition, and Prinzmetal angina which involves coronary artery spasm. Angina is typically diagnosed through ECG or coronary angiography and can be managed through risk factor modification, pharmacological treatments like beta blockers, calcium channel blockers, and nitrates, and potentially surgery. The most important treatment is modifying risk factors such as smoking, diet, exercise, and controlling conditions like high blood pressure and cholesterol.

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

4.  Stable angina:
 Most common type of angina
 Common in smokers, hypertensive patients
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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
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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
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7. 7
 Coronaries narrow
by plaque lead to
stable angina
 Clot formation
lead to
unstable angina
Video

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 videoWhat Causes Angina -
presentation.wmv

9.  The common symptoms:
 Chest pain
 Squeezing of the chest
 Uncomfortable pressure
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10.  Chest pain that may spread to :
○ Left shoulders
○ Neck
○ Arms
○ Jaws
 The pain is milder when leaning forward
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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
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13.  Minor Controllable
○ Lack of exercise
○ Personality
○ Extreme temperatures
○ Emotional Stress
○ Alcohol Abuse
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14.  ≥ 3 CAD risk factors
(↑cholesterol, DM , smoking , HTN).
 Prior CAD (cath stenosis ≥ 50%).
 ≥ 2 anginal events----- ≤ 24 hours.
 ST segment deviation.
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15.  ECG ------ non-invasive (85% accurate).
 Exercise stress test with ECG .
 Holter monitoring (24 hrs ambulatory ECG).
 Cardiac catheterization
 Diagnostic
 Therapeutic
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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)
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18.  Insertion of a catheter to coronaries
 Dye is injected
 Detect blocks
 Accurate
 Effective
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×Exclude people from treatment based
on their age.

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

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×Offer vitamin or fish oil supplements

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

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×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

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Management
Risk factor
modification
Pharmacological
management Surgery

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 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
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27.  Pharmacological Management
include:
 Beta blockers
 calcium channel blockers
 Nitrates
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28.  Pharmacological Management
include:
 Antiplatelets
 Other agents
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Beta
Blockers Selective β1
Atenolol
Acebutolol
Metoprolol
Bisoprolol

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Beta
Blockers Nonselective
Propranolol
Timolol
Nadolol

31.  Pharmacological effects:
 ↓ myocardial oxygen consumption by:
○ ↓ heart rate
○ ↓blood pressure
○ ↓ myocardial contractility
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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.
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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.
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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
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38.  Ranolazine
 Inhibits fatty acid oxidation
 Inhibits late sodium current into
myocardial cells
 Prolongs QT interval
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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
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40.  Surgical options includes:
 CABG
 Veins from
○ Saphenous vein (leg)
 Arteries from
○ Internal mammary artery (chest)
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41.  Surgical options inlcludes:
 PCI
o Use balloon
o Use stent
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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
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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
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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

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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
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48.  Angina is presented mainly as:
 Chest pain that may spread to :
○ Left shoulders
○ Neck
○ Arms
○ Jaws
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49.  Angina can be diagnosed by:
 ECG (stress)
 Coronary angiography
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DON’T Offer TENS, EECP or
acupuncture

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×Offer vitamin or fish oil supplements

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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