Related with cardio vascular system. Angina is Retrosternal chest pain which if left untreated can cause the higher complications with respect to cardiac health of human body. May be this is simple chest pain but if exceeds can cause major damage # prevention is better than cure :-)

1. A Case presentation on
Angina Pectoris
By,
Umme Habeeba A Pathan
Roll no: 27
Pharm-D 2nd year
Bapuji Pharmacy College

2. DEFINITION
• Angina is the result of myocardial ischemia caused by an imbalance
between myocardial blood supply and oxygen demand.
• It is medical term used for Retro sternal chest pain.

3. CLASSIFICATION OF ANGINA
• Angina is classified broadly as stable or unstable, depending on its pattern
of occurrence and severity.
• Stable angina occurs when increased
physical activity (e.g., hurrying across
a street or climbing a long stairs) which
creates a greater demand for oxygen-rich
blood to reach heart tissue.
• Unstable angina occurs with lesser
degrees of exertion or while at rest.
Unstable angina that occurs at rest is the
most serious form.This type usually is
caused by the formation of a blood clot at
the site of a ruptured plaque in a coronary artery.

4. Others type of angina include
• Variant angina occurs at any time nearly always when person is resting.
Attacks can be very painful and usually happen between midnight and 8 am.
It is caused by the spasm in the coronary arteries.
The spasm usually occur very close to blockage.
• Micro-vascular angina is recently discovered syndrome, patients with this
condition experiences chest pain but have no apparent coronary artery
blockade.
Causes are spasms within the walls of these very small arterial blood vessels
causes reduced blood flow to the heart muscle leading to a type of chest
pain referred to as micro-vascular angina.
May occur with the shortness of breath, sleep problem, fatigue and lack of
energy.

5. Pathophysiology
• Angina pectoris typically occurs when myocardial oxygen demand exceeds
myocardial oxygen supply (perfusion).
• The underlying pathologic condition of this mismatch invariably is the
presence of atherosclerosis in one or more of the epicardial coronary
artery (conductance vessels).
• Collateral blood vessels (i.e., side branches of a coronary artery that join
one of the three principal arteries or connect two points along the same
artery) may offer protection against myocardial ischemia.
• These usually are very small and have no function in the normal heart. If
blood flow is obstructed, however, collateral vessels assume more
importance and can restore some myocardial blood flow. When
myocardial oxygen demand is increased excessively, however, collateral
blood flow usually is insufficient, and angina or other myocardial ischemia
syndromes develop.

6. Atherosclerosis Arterial spasm
Atherosclerosis + Plaque +
Thrombus
Gradual obstruction
Sudden reversible
obstruction
Sudden irreversible
obstruction
ISCHAEMIA
Hypoxia
Reduced oxygen demand
Thrombolysis
Angina
Unstable
angina

7. Clinical Presentation
• Angina is a symptom of ischemic heart disease (IHD). Episodes of stable
angina typically are brought on by exertion or emotion and are relieved
with rest. An attack of stable angina lasts from 1 to 5 minutes and is
described as - squeezing,
- choking,
- smothering, or
- crushing pressure in the chest.
• Angina pain may radiate to the shoulders,
arms, back, neck, or jaw.
• Patients with atherosclerosis also may
experience sweating, clamminess,
shortness of breath (dyspnea).
• Unstable angina causes symptoms that are more severe, more frequent,
and occur with modestly increased physical activity and at rest.
• Blood clots may form at anytime and may partially dissolve spontaneously.
Whenever this occurs, blood flow to heart tissue is blocked and angina
occurs.
• An attack of unstable angina may last several minutes to half an hour or
longer.
• Unstable angina is an acute coronary syndrome, which is a medical
emergency that requires immediate attention.

8. Diagnosis
• Chest radiography: Usually normal in AP but may show cardiomegaly in
patients with previous MI, ischemic cardiomyopathy, pericardial effusion or
pulmonary edema.
• Gradient exercise stress testing: This is the most widely used test for the
evaluation of patients presenting with the chest pain and can be performed
alone and in conjunction with echocardiography or myocardial perfusion
scintography.
• Coronary artery calcium (CAC) scoring by fast CT: The primary fast CT
methods for this application are EBCT and MDCT.
• ECG: It detects and record the electrical activity of heart. Certain electrical
patterns that the ECG detects can suggest whether CAD is likely. However,
some people with angina have a normal ECG. The ECG is usually normal
between attacks. During an attack there may be a transient ST segment
depression. If the angina is provoked by exertion, an exercise stress ECG
should be performed.
• Blood Tests: Blood tests check the levels of certain fats, cholesterol, sugar, and
proteins in blood. Abnormal levels may indicate risk factors for CAD.

9. TREATMENT MANAGEMENT
Non pharmacological treatment
• Monitoring high blood pressure through DASH eating plan.
• Monitoring high cholesterol by dietary therapy.
• Quit smoking.
• Lose excess weight.
• Reduce stress.

10. Pharmacological treatment
• Nitrates :Nitrates improve blood flow by relaxing and dilating veins and
arteries, including the coronary arteries.
Examples: nitroglycerin and isosorbide dinitrate.
Side effects: The most common side effects of nitrates are headache,
lightheadedness, flushing, and an increase in heart rate.
• ACE Inhibitors: It blocks the degradation of bradykinin and stimulates the
other vasodilating substances including prostaglandin E2 and prostacyclin.
Examples: Benazapril, Captopril, Enalapril, Ramipril.
Side effects: Hyperkalemia, angioedema, dry cough.
• Calcium channel blockers: Calcium channel blockers dilate arteries and
lower blood pressure, which decreases the force of contractions. They also
dilate veins, reducing the amount of blood returning to the heart, which
reduces the workload of the heart.
Examples: amlodipine, nifedipine, nicardipine, verapamil and diltiazem.
Side effects: flushing, dizziness and lightheadedness, headache, peripheral
edema and depression of cardiac function (with non-dihydropyridines)

11. • Antiplatelet Therapy: Works by blocking platelets from sticking together
and prevents them from forming harmful clots.
Example- aspirin, clopidogrel
Side effects- Hypotension, tachycardia, bruising stomach, constipation.
• Hormone Replacement Therapy: It is a treatment option for individual
suffering from low levels of naturally occurring hormones like estrogen,
progesterone and androgen.
Examples-Conjugated equine estrogens (Premarin)
Side effects- Adverse effects of estrogen include nausea, headache, breast
tenderness, and heavy bleeding.
• Revascularization therapy.
Percutaneous Coronary Intervention (previously called Angioplasty or
Balloon Angioplasty)
CABG (Coronary Artery Bypass Graft Surgery)

12. SUBJECTIVE
• NAME : XYZ
• AGE : 67 yrs
• SEX : Female
• IP No. : 16881
• UNIT : MED I
• DOA : 23/03/2018.

13. • REASONS FOR ADMISSION :
C/o chest tightness, anxiety, left shoulder and hand pain, weakness.
One day before admission she was severely dyspnic & distressed.
• PAST MEDICAL HISTORY : K/C/O hypertension
• PAST MEDICATION HISTORY: Under the treatment of Telmisartan since 10
years.
• FAMILY HISTORY: Father died due to heart attack at age of 40.
• ALLERGIES AND SOCIAL HISTORY: Nil

14. OBJECTIVE
O/E
• Weight : 86 kg
• BP : 130/90mmHg
• PR : 90bpm
• CVS : S1S2 +ve murmurs heard
• RS : B/L NVBS + ,
• CNS : Conscious and oriented
• Temperature : Afebrile

15. LAB INVESTIGATION
PARAMETERS OBSERVED VALUE NORMAL VALUE
Hb 11.6g/dl 14 – 18g/dl
RBC 3.5 × 10⁶cells/mmᶟ 4.3 – 5.9 × 10⁶cells/mmᶟ
PCV 42 % 39 – 49 %
MCV 88 µmᶟ 76 – 100µmᶟ
MCH 21pg/cell 27 – 33pg/cell
MCHC 25g/dl 33 – 37g/dl
PLATELET 135 × 10³/mmᶟ 130 – 400 × 10³/mmᶟ
TROPONIN LEVELS 0.2 ng / ml 0.1ng/ml
ESR 18mm in 1ᶳᵗ hour 0 – 20mm in 1ᶳᵗ hour
CRP 2.9mg/dl <3.0mg/dl
MYOGLOBIN LEVELS 78 ng / ml 10 – 65 ng / ml
CPK 110mcg/dl 10-120mcg/dl

16. LIPID PROFILE TEST
PARAMETERS OBSERVED VALUES NORMAL VALUES
Cholesterol 190mg/dl < 200mg/dl
Triglycerides 178mg/dl < 160mg/dl
LDL 140mg/dl < 130mg/dl
HDL 55mg/dl > 45mg/dl

17. CAC SCORE BY CT SCAN
PARAMETERS OBSERVED VALUE NORMAL VALUE
CORONARY CALCIUM SCORE 0 0 (Risk of CAD very low)
1-10 (Risk of CAD low)
11-100 (Mild or minimal
coronary narrowing)
101-400 (Mild CAD highly
likely)
>400 (Highly likelihood of at
least 1 significant coronary
narrowing)

18. TECHNICAL INFORMATION: Multiple 2.5mm helical CT images of the heart
were obtained . The images were analyzed and scored for coronary calcium
content. Calcium scores were derived and reviewed. Number of images
reviewed 59.
INTEPRETATION :
TOTAL CALCIUM SCORE: 0
This total score is the amalgamation of calcium score in the left main
coronary artery, the left anterior descending coronary artery, the
circumflex coronary artery and the right coronary artery and their
branches. No significant calcium deposits were identified in any of these
major coronary artery distributions.
A total score of 0 indicates that no atherosclerotic plaque was identified,
and that the risk of significant underlying coronary artery disease is very
low.

19. ASSESSMENT
PROVISIONAL DIAGNOSIS OF ANGINA PECTORIS

20. GOALS OF TREATMENT
• To relieve signs and symptoms of Angina.
• To relieve the dyspnic condition of patient.
• To prevent further complication of CAD.
• To improve the quality of life of patient.

21. PLAN
• DAY 1
DRUGS DOSE FREQUENCY MAX DOSE
IVF NS Q6h
TAB.Carvedilol 12.5mg 1-0-1 25mg
TAB. Aspirin 80mg 1-0-0 325mg
TAB. Capoten 12.5mg 1-0-1 25mg
TAB. Atorva 20mg 0-0-1 80mg
TAB. Omeprazole 20mg 0-0-1 40mg
TAB.FEOSOL
(ferrous sulphate)
300mg OD 400mg

22. DAY 2
PARAMETERS Rx
O/E
BP:130/85 mmHg
LDL:135mg/dl
TriG: 175mg/dl
Troponin levels: 0.1ng/dl
CST
IVF STOPPED
DAY 3
PARAMETERS Rx
O/E
BP: 130/90mmHg
LDL: 135mg/dl
HDL:175mg/dl
Pt complain of constipation
CST
Add syp.lactulose
15ml PO

23. DAY 4
PARAMETERS Rx
O/E
BP: 120/85mmHg
CST
Patient dispnic
condition was improved
DISCHARGE MEDICATION
DRUGS DOSE FREQUENCY NO OF DAYS MAX DOSE
NIFEREX 150 – Forte(Vit
B12, Vit C , iron
supplement)
5ml OD 15 days 10ml
TAB.ATAST(Atorvastatin) 10mg 0-0-1 5 days 20mg
TAB.TELMISARTAN 20mg 1-0-0 CONTINUE 80mg
VISIT AFTER 15 DAYS

24. GOALS ACHIEVED
• Retro sternal pain has been controlled.
• Signs and symptoms were reduced.
• Patients condition became better.

25. INTERACTIONS
• No major interactions were found.
• Moderate interactions include
Captopril <> Aspirin
Dose adjustment should be done as it decreases kidney function.
Omeprazole <> Fe multivitamin
omeprazole may reduce the absorption of iron multivitamin
Atorvastatin <> Omeprazole :
Combining these medications may increase the blood levels and may
increase the risks of side effects like liver damage.

26. MEDICATION INDICATION
• IVF NS is a fluid replenisher.
• Tab.Carvedilol is to treat BP and improve the chance of survival when
heart is not pumping well.
• Tab. Aspirin is used as an anti-platelet agent and for the treatment of
chest pain.
• Tab. Capoten is used to treat high BP and help the heart to pump blood
well as it did before.
• Tab. Atorvastatin is an HMG-Co A reductase inhibitor used in the
treatment of cardiovascular diseases.
• Tab .Omeprazole is a proton pump inhibitor & inhibits the secretion of
gastric acid.
• Tab. Feosol (ferrous sulphate) is an iron supplement used for treatment of
low blood levels of iron.
• Syp.lactulose is given to treat constipation.
• Tab.captopril is used to treat hypertension.

27. PATIENT COUNSELLING
o ABOUT MEIDICATIONS
• Take medicines prescribed properly, don’t refill prescription unless advised.
• Inform physician for any side effects.
• Don’t double the dose if missed.
o ABOUT DISEASE
• Periodic screening for hypertension and other cardiac risks.
• Educating patient about the risks leading after an attack of angina.
o ABOUT LIFESTYLE MODIFICATION
• Drink lots of water.
• Low physical activity.
• Take iron rich balanced diet.
• Adequate fluid intake.
• Avoid excess salt & FATTY intake.

28. THANK YOU