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This lecture was conducted during the Nephrology UnitGrand Ground by Medical Student rotated under Nephrology
Division under the supervision and administration of Prof.
Jamal Al Wakeel, Head of Nephrology Unit, Department of
Medicine and Dr. Abdulkareem Al Suwaida, Chairman of theDepartment of Medicine. Nephrology Division is not
responsible for the content of the presentation for it is
intended for learning and /or education purpose only.
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Definition of Angina Pectoris
is the result of myocardial ischemia caused by animbalance between myocardial blood supply andoxygen demand.
Angina is a common presenting symptom
(typically, chest pain) among patients withcoronary artery disease.
Angina pectoris is more often the presentingsymptom of coronary artery disease in women thanin men.
Increase with age
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Types of angina
1. Stable angina.
2. Unstable angina
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Stable angina
is that occurs when coronary perfusion isimpaired by fixed or stable atheroma of
coronary arteries.
Ex. Pt. has fixed capacity of exertion afterhe starts feeling chest pain.
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Unstable angina
is that characterized by rapidly worseningchest pain on minimal exertion or at rest.
= ulcerated atheroma+ thrombusformation>>> reduction of coronary blood
flow caused by thrombus>> angina at rest
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Unstable angina
Recent onset (less than 1 month).
Increase frequency and duration of episode.
Angina at rest not responding readily to
therapy. If the pain more than 30 min.????
MI
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Stable Angina Classification
Exertional
Variant or Prinzmetals Angina
Anginal Equivalent Syndrome
Syndrome-X Silent Ischemia
Decubitus angina
Noctural angina
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Exertional or classical
It occurs due to increase myocardial oxygendemand during exertion or emotion in a
patient of narrow coronary arteries. It
relieved by rest and nitroglycerine. Coronary artery obstructions are not
sufficient to result in resting myocardial
ischemia. However, when myocardial
demand increases, ischemia results.
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Variant or Prinzmetals Angina
Transient impairment of coronary bloodsupply by vasospasm or platelet aggregation
Majority of patients have an atherosclerotic
plaque Generalized arterial hypersensitivity
Long term prognosis very good
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Prinzmetals Angina
Spasm of a large coronary artery
Transmural ischemia
ST-Segment elevation at rest or with
exercise More prolonged than in classical angina.
It occurs more in women under age 50.
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Anginal Equivalent Syndrome
Patients with exertional dyspnea rather thanexertional chest pain
Caused by exercise induced left ventricular
dysfunction
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Silent Ischemia
Very common
More episodes of silent than painfulischemia in the same patient
Difficult to diagnose Holter monitor
Exercise testing
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Holter monitor
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Decubitus angina
Occurs when pt. lies down.
Usually ass. With impaired LV function.
Pt usually has severe CAD when pt, has
these symptoms,
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Noctural angina
It awakes the pt. from sleep,
It may provoked by vivid dreams.
It may occur due to CAO or coronary spasm
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The Canadian Cardiovascular Society
grading scale
is used for classification of angina severity, as follows:
Class I: Angina only during strenuous or prolonged physicalactivity
Class II: Slight limitation, with angina only during vigorousphysical activity Class III: Symptoms with everyday living activities, ie, moderate
limitation
Class IV: Inability to perform any activity without angina or
angina at rest, ie, severe limitation
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Causes:
Decrease in myocardial blood supply due to increasedcoronary resistance in large and small coronaryarteries:
1. Significant coronary atherosclerotic lesion in the large epicardialcoronary arteries (ie, conductive vessels) with at least a 50%
reduction in arterial diameter2. Coronary spasm (ie, Prinzmetal angina)3. Abnormal constriction or deficient endothelial-dependent relaxation
of resistant vessels associated with diffuse vascular disease (ie,microvascular angina)
4. Syndrome X
5. Systemic inflammatory or collagen vascular disease, such asscleroderma, systemic lupus erythematous, Kawasaki disease,polyarteritis nodosa, and Takayasu arteritis
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Cause cont.
Increased extravascular forces, such as severe LVhypertrophy caused by hypertension, aortic stenosis, orhypertrophic cardiomyopathy, or increased LV diastolicpressures
Reduction in the oxygen-carrying capacity of blood, such aselevated carboxyhemoglobin or severe anemia (hemoglobin
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Causes cont.
Structural abnormalities of the coronaryarteries
1. Congenital coronary artery aneurysm orfistula
2. Coronary artery ectasia
3. Coronary artery fibrosis after chest radiation
4. Coronary intimal fibrosis following cardiactransplantation
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Risk factors:
Major risk factors for atherosclerosis: like familyhistory of premature CAD, cigarette
smoking,DM,hypercholesterolemia(Metabolic
syndrome), or systemic HTN
Other risk factors: These include LV hypertrophy,obesity,
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http://emedicine.medscape.com/article/150916-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/165124-overviewhttp://emedicine.medscape.com/article/150916-overview8/11/2019 angina pectoris-101111112
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Precipitating factors:
These include factors such as severeanemia, fever, tachyarrhythmias,
catecholamines, emotional stress, and
hyperthyroidism, which increase
myocardial oxygen demand.
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Preventive factors:
Factors associated with reduced risk ofatherosclerosis are a high serum HDL
cholesterol level, physical activity,
estrogen, and moderate alcohol intake (1-
2 drinks/d).
???!! Plz Dont drink and smoke 4u life.
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Stable Angina
Evaluation of LV Function
Physical exam CXR
Echocardiogram
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Stable Angina
Evaluation of Ischemia
History Baseline Electrocardiogram
Exercise Testing
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CCSC Angina Classification
Class I
Class II
Class III
Class IV
Angina only withextreme exertion
Angina with walking
1 to 2 blocks
Angina with walking
1 block
Angina with minimal
activity
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ECG
ST segment depression with or without Twave inversion that reverse after ischemia
disappears.
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ECG
Elevation of ST segment in prinzmentalsangina.
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ECG
The resting ECG may be normal betweenattacks however it may show old MI, heart
block or LVH
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Stable Angina
Exercise Testing
The goal of exercise testing is to induce acontrolled, temporary ischemic state during
clinical and ECG observation
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Angina: Exercise Testing
High Risk Patients
Significant ST-segment depression at lowlevels of exercise and/or heart rate
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Angina: Exercise Testing
Low Risk Group
CASS Registry: 7 year survival
Less than 1 mm ST depression in Stage IIIof Bruce Protocol
Annual mortality: 1.3%
JACC 1986;8:741-8
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Exercise Testing
Contraindications
MIimpending or acute Unstable angina Acute myocarditis/pericarditis Acute systemic illness
Severe aortic stenosis Congestive heart failure Severe hypertension
Uncontrolled cardiac arrhythmias
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Stable Angina
Stress Echo
Ischemia may cause wall motion abnormalities, norise of fall in LVEF ( left ventricular ejection fraction)
This formula gives one a fraction, e.g., 0.60. Multiply this fraction by 100 gives a % figure, e.g., 60%
Sensitivity/specificity same as nuclear testing
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Cardiac Catheterization
Indications
Suspicion of multi-vessel CAD Determine if CABG/PTCA feasible
Rule out CAD in patients with
persistent/disabling chest pain andequivocal/normal noninvasive testing
percutaneous transluminal coronary angioplasty
coronary artery bypass grafting
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Angina: Treatment Goals
Feel better Live longer
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Stable Angina
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Stable Angina
Treatment Options
Medicine Percutaneous
Intervation
CABG
Angina
Treatment Options
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Stable Angina
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Stable Angina
Non-Invasive Evaluation
Coronary Arteriography
LV Dysfunction
Coronary Arteriography
High Risk
Medical Therapy
Stable
Coronary Arteriography
Recurrent Angina
Medical Therapy
Low Risk
Stress Testing
Normal LV Function
Resting LV Function
(Clinical Assessment)
Nondisabling Angina
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Stable Angina
Treatment Options
Medical Treatment
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bl i
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Stable Angina
Current Pharmacotherapy
Beta-blockers Calcium channel blockers
Nitrates
Aspirin Statins
? ACE inhibitors
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S bl A i
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Stable Angina
Considerations when Choosing a Drug
Effect on myocardium Effect on cardiac conduction system
Effect on coronary/systemic arteries
Effect on venous capitance system Circadian rhytm
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Reference
Medical diagnosed and mangement 8th2006 ,mohammedDanish OHCM 7th 250 cases in clinical examination. pocket clincal medicine 3nd. Kumar & Clark http://www.ncbi.nlm.nih.gov/ http://emedicine.medscape.com/article/150215-overview http://www.heartfailurematters.org http://health.allrefer.com/
Ect..
N.A.N 2009
http://www.ncbi.nlm.nih.gov/http://emedicine.medscape.com/article/150215-overviewhttp://www.heartfailurematters.org/http://health.allrefer.com/http://health.allrefer.com/http://www.heartfailurematters.org/http://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://emedicine.medscape.com/article/150215-overviewhttp://www.ncbi.nlm.nih.gov/8/11/2019 angina pectoris-101111112
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THANKS 4 HEARING MY
PRESENTATION
I hope that it is usefulMy best regards
NASRULLAH NASRULLAH (N A N)
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