This document discusses chronic coronary syndrome, also known as stable angina. It describes the pathophysiology as fixed atherosclerotic lesions causing an imbalance between myocardial oxygen supply and demand, leading to demand-induced ischemia. The key clinical features are chest pain or discomfort that is precipitated by exertion or stress and relieved by rest. Investigations include electrocardiograms, stress tests, echocardiography, myocardial perfusion scans, CT coronary angiography, and invasive coronary angiography to diagnose coronary artery disease and determine management.

1. Coronary artery diseases
Chronic coronary syndrome (2019)
Chronic stable angina

2. objectives
• To be able to describe and classify angina
• Apply knowledge of coronary circulation physiology and pharmacology of anti-
anginal drugs to Formulate management plan according to patient profile
• Apply knowledge of coronary anatomy to analyze ECG changes and identify area of
ischemia and culprit artery
• List non invasive investigations for the diagnosis of CAD and risk stratification and
their limitations and variation in sensitivity/specificity and cost
• Choose stress tests according to patient profile
• List indications for coronary angiography in stable angina
• Recall treatment modalities for refractory angina
• Recall indications for mechanical revascularization: PCI vs. CABG
• Discriminate between PCI and CABG in term of effectiveness and survival benefit
• Recall factors affecting prognosis

4. Right dominance vs Left dominance

6. Coronary circulation
• Coronary flow occurs mainly during diastole
• Normal coronaries can increase its blood flow
4 - 7 times during maximum exercise.
• At least 70% stenosis → limit flow during
exercise
• > 90 % stenosis → angina at rest.
• Small collateral vessels interconnect the
coronary arteries.

7. Factors influencing myocardial O2 supply and
demand

8. Stages of atherosclerosis (‫فقط‬ ‫)لالطالع‬

9. Risk factors for atherosclerosis
• Age: men ≥ 45 years; women ≥ 55 years.
• Male sex
• Family history: 1st degree relatives < 55 yr for men and < 65
yr for women.
• Smoking: dose-linked relationship
• Hypertension.
• Dyslipidemia: Low HDL cholesterol and high LDL or TG
• DM
• Sedentary life.
• Obesity: BMI ≥ 30 kg/m2, particularly if central or truncal.
• Heavy alcohol intake
• Dietary factors

10. CHRONIC CORONARY SYNDROME
• Pathophysiology: fixed atherosclerotic lesions
>> obstruction >> imbalance between
myocardial oxygen supply and demand
• Demand led ischemia
• angina that is stable in frequency and severity
for at least 2 months and with which the
episodes are provoked by exertion or stress of
similar intensity

11. Clinical features
• The history is by far the most important factor in
making the diagnosis.
• precipitated by exertion (during and not after) or
other forms of stress e.g. Cold exposure, heavy
meals, or intense emotion.
• Relieved with rest or GTN
• episodes usually last 3-10 min (average 5 min)
• Decubitus angina: less common
• Angina equivalent: SOB, fatigue, eructation

14. Types of CCS angina
Typical angina
1. Sub-sternal chest discomfort
2. Induced by exertion
3. Relieved by rest or NTG
Atypical angina: two out of the three of the
above.
Non-anginal chest pain one or less of these
features.

15. Physical examination
• Frequently negative.
• During acute anginal episode: may be S4, diaphoresis,
crackles, and a transient murmur of mitral regurgitation due
to papillary muscle ischemia.
• Look for
– Risk factors: HTN , DM , nicotine staining, xanthelasma
– Evidence of generalized arterial disease: e.g. carotid bruits,
peripheral vascular disease or retinal vascular
abnormalities.
– Exacerbating conditions e.g. obesity, anemia,
thyrotoxicosis, aortic valve disease.

17. Common causes of chest pain

18. Differential diagnosis of chest pain
according to location

19. Case 1
• 40 yr old female presented with one week h/o
recurrent inframammary chest pain that usually
occur at rest lasting few seconds. The pain
increase by deep inspiration. She has no
associated nausea or vomiting, sweating, SOB,
cough, or fever. She was able to point to the site
of pain with one finger and it was tender to
palpation. P/E negative. ECG and echo normal.
• What is the most likely diagnosis?
• What further tests do you recommend?

20. Case 2
• A 58-year-old woman presents with an 3 months
history of substernal chest tightness and pressure that
radiates to the left arm. The discomfort occurs
predictably after walking 200 meter on ground level
and one flight upstairs that causes her to stop all
activity to resolve with 3 to 4 minutes of rest. Physical
examination, vital signs, and resting ECG are normal.
Her ECG during chest pain showed ST depression in
V1- V4 that resolved with GTN.
• What is the most likely cause of her symptoms?
• What functional class is she ?
• What is the culprit artery?

21. Classification of angina severity according to
Canadian Cardiovascular Society
Class I Ordinary physical activity does not cause angina: Angina
with strenuous or rapid or prolonged exertion at work or
recreation.
Class II Slight limitation of physical activity: angina on walking or
climbing stairs rapidly, walking or climbing stairs after meals, or
in cold, wind, or under emotional stress, or only during the first
few hours after awakening, walking > two blocks on the level or
climbing > one flight of ordinary stairs at a normal pace and in
normal conditions.
Class III Marked limitation of physical activity: angina on walking 1 or
2 blocks on the level or one flight of stairs
Class IV Inability to carry any physical activity without discomfort,
angina syndrome may be present at rest
Block = 100 – 200 m

22. Investigations
• General: blood sugar, renal function test, GUE
including microalbuminuria, Hb, lipid profile, CRP, CXR,
and if indicated thyroid function tests.
• Resting ECG:
– often normal
– Reversible ST ± T wave ↓ at the time of pain
• Echocardiography: regional wall motion abnormalities
(RWMA), assess LV function, exclude other diagnoses
• Stress tests: either for diagnosis and/or risk
stratification
• Coronary angiography

23. ECG during angina (what is the culprit artery)

24. after the administration of sublingual
nitroglycerin

25. Can you localize area of ischemia? Which artery is involved?
Anterior wall → LAD artery
Lateral wall → LCX artery
Inferior wall → RCA (85% of cases and 8 % LCX of cases )

27. ECHOCARDIOGRAPHY
• Look for resting regional wall motion
abnormality (hypokinesia, akinesia, or
dyskinesia)
• Look for LVH, HOCMP or aortic Valvular heart
disease (especially AV stenosis)
• Assess LV function
• Exclude pulmonary hypertension (may cause
exertional angina)

28. Determine likelihood of CAD to
determine 1st line investigation:
• If CAD risk is low (10-29%): perform CT
calcium scoring >>> score 0 : look for
alternative diagnosis, 1-400 perform CTCA, >
400 perform invasive angiography.
• If CAD risk intermediate (30-60%): perform
functional testing (MPI, SPECT, stress MRI,
stress ECHO)
• If CAD risk high (61-90%): perform invasive
coronary angiography

29. Pre-test probabilities of obstructive CAD in 15 815 symptomatic patients
according to age, sex, and the nature of symptoms ( ‫لالطالع‬
‫فقط‬ )
• The regions shaded dark green denote the groups in which non-invasive testing is most beneficial
(PTP >15%). The regions shaded light green denote the groups with PTPs of CAD between 5-15%, in
which testing for diagnosis may be considered after assessing the overall clinical likelihood based
on the modifiers of PTPs presented in Figure 3

32. STRESS TESTS
• Exercise ECG (TMT)
• Stress echo
• Myocardial perfusion scan
• Pharmacological stress tests in
combination with echo or
myocardial perfusion scan

33. Sensitivity and specificity of stress tests
(‫فقط‬ ‫)لالطالع‬
TMT
isotope scan ≥ stress echo > TMT

34. Stress tests – cost issues (‫فقط‬ ‫)لالطالع‬
Exercise ECG (TMT) 1 X
Stress echo 2 X
Stress SPECT myocardial scan 5 X
Coronary angiography 20 X

35. Stress tests (‫فقط‬ ‫)لالطالع‬
Subgroup Recommended Study
Pt able to exercise
If baseline ST-T on ECG is normal Standard exercise test (treadmill, bicycle,
or arm ergometry)
If baseline ST-T impairs test interpretation
(e.g., LVH with strain, digoxin)
Standard exercise test (above) combined
with either: Perfusion scintigraphy or
Echocardiography
Pt not able to exercise (regardless of
baseline ST-T abnormality)
Pharmacological stress test (dobutamine,
dipyridamole, or adenosine) combined
with imaging: (Perfusion scintigraphy or
Echocardiography)
LBBB on baseline ECG Adenosine (or dipyridamole) SPECT or PET
scintigraphy

36. What stress test would you choose for
the following patients
• 45 yr old male with stable angina and normal
ECG.
• 55 yr old female with stable angina, normal
ECG, and severe OA changes of both knees
• 55 yr old female with stable angina and LVH
with strain pattern (fixed ST depression in
lateral leads).
• 48 yr old male with stable angina and LBBB by
ECG

37. Exercise ECG : diagnosis and risk
stratification

38. ECG changes during exercise ECG
(TMT) (‫فقط‬ ‫)لالطالع‬

39. Exercise ECG (‫فقط‬ ‫)لالطالع‬

40. STRESS ECHOCARDIOGRAPHY

41. Myocardial perfusion scan

42. Myocardial perfusion scan

43. CTCA
• CT coronary angiography is particularly useful
in the initial elective assessment of patients
with chest pain and a low or intermediate
likelihood of disease, since its negative
predictive value is very high: that is, excluding
the presence of CAD.

44. Coronary CTA is not recommended
• Allergy to iodinated contrast
• Extensive coronary calcification
• Irregular heart rate e.g. AF
• significant obesity
• inability to cooperate with breath-hold
commands
• Clinical instability (e.g., acute respiratory distress,
severe hypotension, unstable arrhythmia)
• Renal impairment

45. CORONARY ARTERIOGRAPHY: INDICATIONS
• When non-invasive tests are not possible or non – diagnostic
• High-risk results of noninvasive testing.
• To assess for non atherosclerotic CAD e.g. spasm, coronary artery
anomaly.
• Severe angina (CCS class III or IV) with optimal medical therapy or any
patient with class I to II angina who is intolerant of medical therapy
• Survivors of sudden cardiac arrest or life-threatening vent. arrhythmia
• Symptoms of congestive heart failure with angina
• Patients with careers that involve the safety of others (e.g., pilots,
firefighters, police)
• should not be performed in patients with angina who refuse invasive
procedures, prefer to avoid revascularization, who are not candidates for
(PCI) or (CABG), or in whom revascularization is not expected to improve
functional status or quality of life

46. Coronary angiography

47. Risk stratification (‫)لالطالع‬
Highrisk Lowrisk
Post-infarctangina
Poorefforttolerance
Ischaemiaatlowworkload
Leftmainorthree-vesseldisease
PoorLVfunction
Predictableexertionalangina
Goodefforttolerance
Ischaemiaonlyathighworkload
Single-vesselortwo-vesseldisease
GoodLVfunction

48. Treatment - General
• Smoking cessation
• Aim at ideal body weight (BMI < 25 kg/m2)
• Diet: Mediterranean food
• Exercise: isometric exercise contraindicated.
Aerobic/isotonic exercise 5x/week 30 -60 min per session .
• Identify and treat risk factors:
– HTN BP <140/90 (consider <130/80 if prior MI)
– DM (HbA1c 7% and <7% if long life expectancy. Tight control
may the risk of CV death and complications).
• Correct exacerbating factors: anemia, hyperthyroidism.
• Influenza vaccine

49. Diet
• Increase consumption of fruits and vegetables ( ≥ 200 g each per day).
• 35 - 45 g of fibre per day, preferably from whole grains.
• Moderate consumption of nuts (30 g per day, unsalted).
• 12 servings of fish per week (one to be oily fish).
• Limited lean meat, low-fat dairy products, and liquid vegetable oils.
• Saturated fats to account for <10% of total energy intake; replace with
polyunsaturated fats.
• As little intake of trans unsaturated fats as possible, preferably no intake
from processed food, and <1% of total energy intake.
• ≤ 5-6 g of salt per day.
• alcohol is consumed, limiting intake to ≤ 100 g/week or <15 g/day
• Avoid energy-dense foods such as sugar-sweetened soft drinks.

50. Optimal medical therapy (OMT):
• Antiplatelet therapy*: either Aspirin (ASA) or clopidogril if ASA intolerant
• Anti-anginal therapy
– Nitrates
– Beta blockers
– Calcium channel blockers
– Potassium channel activators (nicorandil)
– If channel antagonist (Ivabradine)
– Ranolazine
– Trimetazidine
• Statin therapy*(irrespective of serum cholesterol)
• ACE i or ARBS* (especially if HTN, DM, CKD or ↓ EF (≤ 40%)
* improve survival

52. Stepwise strategy for long-term anti-ischemic
drug therapy in patients with CCS

54. Nitrate therapy (‫فقط‬ ‫)لالطالع‬
Preparation Usual dose Peak
action
Duration
of action
Dosing frequency
Short – acting
Sublingual GTN
tab or spray
0.3 – 0.5 mg
0.4 mg / spray
4–8 mins 10–30
mins
As needed
Transdermal GTN 0.1 – 0.6
mg/hr
1–3 hrs Up to 24 hr Apply at morning
Remove at night
Long - acting
Oral (ISDN)
Isosorbide
Dinitrate
5 – 30 mg
SR (40 mg)
45−120
mins
2–6 hrs Tid or
Bid if SR
Oral (ISMN)
Isosorbide
Mononitrate
20 – 40 mg
SR (30-240
mg)
45–120
mins
6–10 hrs Bid (once am
then 7 hr later)

55. Nitrates
• Mechanism
–  myocardial O2 supply (vasodilatation)
– ↓myocardial O2 demand (↓ preload and afterload)
• What do you advice patients about sublingual GTN
– Do not swallow
– Repeat every 5 min up to a max of 3 doses >> hospital if no response (? MI)
– Use while sitting
– encourage to use prophylactically
– avoid w/n 24 h of sildenafil or w/n 48 h of tadalafil >> ↓BP
• Long acting nitrates
– Headache is common but tends to diminish if the patient continue with the
treatment.
– Tolerance → nitrate-free period
– Avoid sudden withdrwal

56. Beta-blockers
• lower myocardial oxygen demand by reducing
HR, BP and myocardial contractility.
• Dosage titrated to resting HR of 55–60 BPM.
• Should not be withdrawn abruptly >>
precipitate arrhythmias, worsening angina, or
MI.
• Contraindicated in patients with vasospastic
angina (CCB are preferred)

57. Calcium channel blockers
• Decrease myocardial oxygen demand by reducing BP and
myocardial contractility.
• Improve oxygen supply by direct coronary vasodilation.
• Dihydropyridine CCB (nefidipine) causes a reflex
tachycardia and best to use in combination with β blocker.
• Non Dihydropyridine CCB (verapamil and diltiazim) are
suitable for pt not receiving β blocker because they cause
bradycardia.
• CCB may aggravate or precipitate HF because of depression
of myocardial contractility.
• Use sustained-release, not short-acting preparations
(increase coronary mortality).

58. Other anti - anginals
• Potassium channel activators (Nicorandil): arterial and venous
dilatation. Does not exhibit the tolerance seen with nitrates
• If channel antagonist (Ivabradine): induces bradycardia by
modulating ion channels in the sinus node. it does not cause ↓BP
or myocardial depression. safe in HF.
• Metabolic modulators: e.g. Ranolazine and trimetazidine.
– They have non mechanical anti-ischemic properties.
– They have no effect on HR or BP.
– Add-on or if β blocker intolerant.
– It is typically used when other medical therapy is insufficient in
controlling angina (refractory angina).
– The former is contraindicated in hepatic impairment and prolonged
QTc interval, and the latter is contraindicated in parkinsonism and
motion disorders.

59. MECHANICAL REVASCULARIZATION
• Percutaneous Coronary Intervention (PCI)
– more effective than medical therapy for relief of angina.
– not shown to reduce risk of MI or death in CSA
– should not be performed on asymptomatic or only mildly
symptomatic individuals.
– PCI is mainly used in single or two-vessel disease.
• Coronary Artery Bypass Surgery (CABG):
– when lesions are not amenable to PCI
– if severe CAD is present (e.g., left main, 3VD with impaired
LV function, and diabetics with CAD in ≥ 2 vessels including
proximal LAD).
– It improves survival in these patients compared to PCI.

60. Percutaneous Coronary Intervention
(PCI)

61. Coronary angioplasty and stenting

63. CORONARY ARTERY BYPASS GRAFTING ( CABG)

64. Refractory angina not amenable to PCI or CABG
• Enhanced external counterpulsation:
– Reduces the frequency of angina and/or the CCS class in up to
80% of patients
– Extends time to exercise-induced ischemia
– Improves quality of life in patients with symptomatic CAD
– Generally well tolerated.
• Spinal cord stimulation (epidural space at the C7-T1 level):
– It decrease angina frequency by up to 80%
– Decrease CCS score
– Improve quality of life.
• Transmyocardial laser revascularization (TMR)
• Coronary sinus reducer

65. PROGNOSIS
• Is related to the number of diseased vessels and the
degree of LV dysfunction.
• Symptoms are a poor guide to prognosis; nevertheless,
the 5-year mortality of patients with severe angina
(NYHA class III or IV) is nearly double that of patients
with mild symptoms.
• Stress testings are better predictor.
• Spontaneous symptomatic improvement is common
due to development of collaterals.
• For patients with multi-vessel disease or diabetes,
CABG appears to confer better survival rates.

66. Case 5
• A 35-year-old woman presented with substernal chest
discomfort radiating to the lower jaw. Her symptoms usually
occur in the morning and often wake her up from sleep. She is
a smoker, but she does not have any other risk factors for
CAD. An ECG obtained when the patient is symptomatic is
significant for ST segment elevation that disappears when the
symptoms resolve. Physical exam and vitals signs are within
normal limits.
• What is the most likely diagnosis?
• Is any other diagnostic test indicated for this patient?
• How are you going to treat this patient

67. PRINZMETAL’S VARIANT ANGINA
• Vasospasm at diseased or normal artery
• Chest discomfort is similar to angina but more severe and
occurs typically at rest, with transient ST-segment elevation.
• Pts are generally younger and do not have the usual risk
factors for atherosclerosis, although cigarette smoking is
frequent.
• Acute infarction or malignant arrhythmias may develop
during spasm-induced ischemia.
• ECG (or ambulatory Holter monitor) → transient ST
elevation;
• Diagnosis confirmed at coronary angiography using
provocative (e.g., IV acetylcholine) testing.
• BBs are contraindicated because blockade of the
vasodilatory effects of B2- receptors may result in
unopposed alpha adrenergic vasoconstriction

69. Syndrome X
• Combination of:
– typical angina on effort
– Objective evidence of ischaemia on stress testing
– Angiographically normal coronary arteries.
• It’s poorly understood but carries a good
prognosis
• Usually respond to medical therapy.