Chronic Stable Angina

complete or partial blockage of the blood vessels that bring oxygenated blood to the myocardium, usually due to atherosclerosis

caused by coronary atherosclerotic plaque formation that leads to an imbalance of O₂ supply and demand resulting in myocardial ischemia (death of tissue)

• discomfort of the the chest, jaw, shoulder, back, or arm
• reproducable pattern of pain associated with a certain level of physical activity
• imbalance between myocardial O₂ supply and demand

• coronary restriction results in reduced blood flow and ischemic pain
• normal or non-obstructed coronary arteries
• typically associated with younger pts with fewer risk factors
• early morning pain
• usually at rest
• relieved with nitroglycerin
• triggers include: hyperventilation, exercise, cold climate, smoking, alcohol, amphetamines, cocaine, non-rx vasoconstrictors

• chest pain while at rest or for prolonged duration compared with the pt's typical chronic angina
• progression in severity and intensity
• occurrence at a lower exertional threshold than the pt's typical chronic angina
• recent onset of severe angina that results in marked limitation of ordinary activity

angina

MI

<50%

at least 70%

• HR
• contractility
• left ventricular wall tension

• coronary blood flow
• O₂-carrying capacity of the blood

• family hx of premature CAD (55yo male or 65 yo female)
• age (45yo male or 55yo female)
• hx of cerebro- or perpheral vascular disease

• smoking
• hyperlipidemia
• diabetes
• HTN
• stress
• obesity
• sedentary lifestyle

• pressure pain (discomfort)
• squeezing
• chest feels heavy
• substernal and can radiate to jaw and arm
• lasts minutes - fleeting sensation of pain
• exertion provokes the pain
• rest and nitroglycerin can relieve the pain

• relief of sx
• improve quality of life and exercise capability
• prevention of complications of CAD such as MI, heart failure, or stroke
• prevention of atherosclerotic progression
• reversal of modifiable risk factors

• frequency of angina attacks
• nitroglycerin use
• exercise tolerance

• revascularization (CABG, Percutaneous Coronary Intervention [PCI])
• Therapeutic Lifestyle Changes (TLC): diet, wt management, physical activity

• B-blockers
• CCBs
• Nitrates
• Ranolazine
• Antiplatelets
• Lipid lowering agents
• antihypertensives

negative chronotrope + negative inotrope = decreased demand

negative chronotrope + negative inotrope = decreased demand

vasodilation decreases myocardial workload = decreased demand

reduces calcium overload in ischemic myocytes = decreased demand

• block L-type (slow) calcium ion channels = decreased contraction of both smooth and cardiac muscle and cells within the SA and AV nodes
• non-DHP: less vasodilator activity

• converted to NO which activates cGMP and vasodilation
• peripheral venodilation leads to decreased venous return
• decreased ventricular end-diastolic pressure
• decreased peripheral arteriolar resistance
• decreased afterload
• decreased myocardial work and O₂ demand

< 130/80

• LDL <100 (<70 if possible)
• non-HDL < 130 (<100 if possible)
• HDL > 40
• TGs < 150

55-60 bpm

• atenolol
• metoprolol tartrate
• metoprolol succinate
• propranolol
• nadolol

as initial therapy in pts with no contraindications

• do not stop abruptly
• titration required
• could mask sx of hypoglycemia so keep close tabs on blood glucose
• may cause fatigue
• may cause orthostatic hypotension
• monitor BP and HR

• hypotension
• bradycardia/heart block
• bronchospasm
• fatigue
• decreased exercise tolerance
• depression
• impotence
• glucose and lipid abnormalities
• peripheral vasoconstriction

• peripheral edema (DHP)
• HA (DHP)
• flushing (DHP)
• dizziness (DHP)
• bradycardia
• AV block
• do not stop abruptly
• constipation (verapamil)

• BP and HR
• BP (DHP)

• diltiazem
• verapamil
• amlodipine (DHP)
• nicardipine (DHP)
• nifedipine (DHP)

• nitroglycerin SL, spray, oral SR, patch, ointment
• isosorbide dinitrate
• isosorbide mononitrate

• when B-blockers are CI
• with BBL when the BBL are unsuccessful
• with nitro if BBL SE are unacceptable
• (if CCB for monotherapy, use non-DHP)

• EVERY pt for immediate relief of angina (SL or spray)
• SL can be used prophylactically 5 min prior to exercise
• when B-blockers are CI (long-acting)
• with BBL when the BBL are unsuccessful (long-acting)
• with CCB if BBL SE are unacceptable (long-acting)

• HA!!
• flushing
• postural hypotension (high doses or 1st dose after nitrate-free period)
• drug rash
• reflex tachycardia

• take 1 at first sign of attack, repeat q 5min if needed (total 3 in 15 min) seek medical attention if no relief on 1st dose
• do not swallow it
• take while sitting (dizziness)
• keep it with you at all times
• keep in original container
• protect from light and heat
• don't use child-proof container
• replace q 3-6 mo once opened
• may cause HA
• do not eat, drink, or smoke within 5-10 min of use

• NOT for acute attacks
• HA may occur
• take oral products on empty stomach
• remove patch for 10-12h/d for nitrate-free period to allow replenishment of sulfhydryl groups
• remove old patch before applying new
• rotate patch sites

• reserved for pts who have not achieved adequate response with other antianginals
• pts who can't tolerate reduction in BP or HR

• QT prolongation
• dizziness
• HA
• constipation
• nausea

• NOT for acute angina attacks
• ECG monitoring
• with or without food
• swallow whole
• limit or avoid grapefruit juice
• ask before starting any new meds (DIs)

when aspirin is absolutely CI

at least 30 min before ibprofen or at least 8h after ibuprofen