Angina Pectoris

coronary heart disease DR.LIU LIXIN

 Definition                         CHD  is  defined  as  myocardial  impairment  due  to  an  imbalance  between  coronary  blood  flow    and    myocardial  requirements  caused  by  changes  in    the  coronary circulation           

classification     

silent myocardial ischemia angina pectoris Myocardial infarction Ischemic cardiomyopathy Sudden death

Presentation

Emergency Department

In-hospital

Acute Coronary Syndrome

Non-ST ↑

Unstable Angina

ST ↑

Non-Q Wave MI

Braunwald E et al. J Am Coll Cardiol 2000;36:970–1062.

Q Wave MI

Stable angina pectoris 

Stable angina pectoris is a syndrome due to myocardial ischemia caused by exertion. It is characterized by episodes of precordial discomfort or pressure. The symptom lasts for several minutes, and relieves by rest or sublingual nitroglycerin. Stable angina pectoris is resulted from the unbalance of oxygen demand and supply. It attacks when oxygen demand exceeds supply.

Symptoms 

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Quality of discomfort (chest pain):Often patients do not perceive the discomfort as pain. The physician must ask about pain equivalents such as strangling, constriction, tightness, squeezing, pressing, heaviness expanding sensation, choking in the throat or indigestion. Location of the discomfort: is most commonly felt beneath the sternum. Pain may radiate to the left shoulder and down the inside of the left arm, even to the fingers.

Symptoms 



Duration of the Discomfort: Stable angina pectoris lasts only a short time, usually 3 to 5 minutes if the precipitating factor is relieved. Precipitating factors: The discomfort tends to occur during, rather than after, the exertion. Overeating, coldness, smoking, tachycardia, Constipation and shock can also evoke the attacks.

Symptoms 

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Frequency:Attacks may vary in frequency from several/day to occasional episodes separated by symptom-free intervals of weeks, or months. Conclusion:Analysis of the symptoms related by the patient, such as the quality of the discomfort, the location of the discomfort, the duration of the discomfort, the precipitating and relieving factors, would offer strong diagnostic clues for angina pectoris.

accessory examination 

Resting electrocardiogram

Stress (exercise) ECG :Treadmill Test

Ambulatory monitoring (Holter): 

a prolonged monitoring of ECG in patients engaged in normal daily activities, it allows to associate the alterations of ST-T contours with patients’ symptoms.

Radionuclide cardiac imaging:

Selective coronary arteriography:

Diagnosis and Differential Diagnosis 

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typical symptoms brought on by exertion and relieved within 1-3 minutes by rest or by sublingual nitroglycerin. ischemic ECG changes during a spontaneous attack or during an exercise ECG test. Coronary arteriography can confirm the diagnosis of angina pectoris

Treatment 

b.

c.

d.

Treatment of acute attack of angina pectoris Resting. To cease activities inducing angina immediately. Nitroglycerin. Nitroglycerin 0.3~0.6 mg (must be fresh) taken sublingually Isosorbide dinitrate. Isosorbide dinitrate 5~10 mg taken sublingually acts within 2-5 minutes

Management of chronic Angina Pectoris Avoidance of precipitating factors  Drug prophylaxis 1.Nitrates: Isosorbide dinitrate (Isoket) 10mg qid orally. Isosorbide mononitrate (Elantan) 20mg bid orally. Nitroglycerin ointment applies to the skin of the chest once daily. 

Drug prophylaxis 2.β-Blockers Propranolol 10mg tid , or metoprolol 25~100mg bid. 3. Calcium channel blockers: Nifedipine 10mg tid . Diltiazem 30~60mg tid or qid. Verapamil 40~80mg tid or qid.

Drug prophylaxis 4.Anti-platelet agents Aspirin 100mg qd Ticlopidine 250mg qd or bid Clopidogrel 75mg qd 5. Lipid-lowering drugs:Statin agents Atorvastatin 20mg qn

Coronary Bypass Surgery and PTCA

Unstable Angina Pectoris and Non-ST segment elevation Myocardial Infarction

etiopathology 



rupture of an atherosclerotic plague within the coronary artery and the subsequent formation of a thrombus over this. coronary spasm

From plaque to thrombosis, key event: plaque rupture

Essentials of Diagnosis Unstable angina 1.New onsent angina: new <2months,frequent >3times/day 2.Accelerated angina: more frequent,severe,prolonged 3.Angina on rest:

Symptoms Non-ST segment elevatin MI  chest pain : increased in frequency, duration, or severity; lasts 30min  new related characters, such as sweating, nausea, emesis, palpitation, or dyspnea.  Routine rest or sublingual nitroglycerin can’t relieve symptoms completely.

Accessory examination 

ECG:

Accessory examination    4.

5.

Holter Coronary arteriography Other tests Total creatine kinase (CK) and its MB isoenzyme (CK-MB) Cardiac-specific troponin (T or I) levels s

Diagnosis and Differential Diagnosis 

The diagnosis of UA can be established according to the typical symptoms and laboratory procedures.

Treatment  2. 3. 4. 5.

General Measures Admission to Hospotial Bed rest Oxygen, electrocardio monitoring sedative

Anti-platelet agents   

Aspirin:75-325mg/d. clopidogrel :75mg/d GPⅡb/Ⅲa receptor antagonists : Tirofiban

Anti-coagulation agents 

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Heparin: 80 U/kg intravenous bolus, then constant intravenous infusion at 18U/kg.h LMWH (Low-molecular-weight Heparins ): Enoxaparin 1 mg/kg SC q12h Fraxiparine 5000u SC q12h

anti-myocardial ischemia 

Nitrates :nitroglycerin ,Isoket(Isoscrbide Dinifrate )

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β-Blockers : Calcium channel blockers :

PCI and Coronary Bypass Surgery