Angina pectoris Mohammed Al Manna - PowerPoint Presentation

1. Angina pectoris Mohammed Al Manna PhD in pharmacology

2. Chest painIn emergency unit ; chest pain either life threatening or simple causes.Danger chest pain may cause by:1. Acute coronary syndrome { STEMI , NSTEMI , or unstable angina}.2. Pulmonary embolism 3.Pneumothorax 4. Aortic dissection 5.Pericarditis 6. Myocarditis 7.Esophageal rupture8. Pulmonary hypertension

3. Non cardiac chest pain ( not dangerous cases)1.GERD2.Peptic ulcer3.Muscles spasm4.Peumonia/ pleuritis5.Herpes zoster6.Gallbladder diseases7.Psychosomatic8.Pancreatitis

4. ..Non-cardiac chest pain Cardiac chest pain the pain may vary from burning to sharp, stabbing and prickling.Chest pain due to anxiety may also result in pain that is similar to cardiac chestPain is dull, constricting, choking and/or crushingNature Pain may be away from the center of the chest where a patient can clearly identify it as a right-sided or left-sided chest pain.Pain is usually localized – located at only one spot which can be clearly pinpointed by the patientThe pain is usually central (towards the center of the chest) and fanning outwards (diffuse).Location There may not often be any radiation of the pain or it may radiate to other sites apart from those mentioned above.Gastritis with accompanying GERD may cause a  burning chest pain as well as upper abdominal pain and this may be confused for radiationPain radiates to the jaw, neck, shoulder, arms or backTypical locations for referred pain are arms (often inner left arm).Sometimes there pain may be radiated to the upper abdomen.Radiation

5. ..Non cardiac chest pain Cardiac chest pain Spontaneous although it may be exacerbated by exertion (usually after rather than during activity).Changes in posture, deep or rapid breathing or pressure may also exacerbate the painTriggered or exacerbated by exertion or emotion.At times a large meal or even extremes of temperature, particularly cold, can trigger or exacerbate the pain.Unstable angina may not be triggered by any specific factorsPrecipitating FactorsNot relieved significantly by rest, if at all.Does not respond to nitrates or there may be a slow response.-Pain relived by antacids may be related to gastrointestinal disorders. Pain is relieved by rest and responds quickly to nitratesRelieving factors

6. ..Non-cardiac chest pain Cardiac chest pain Other signs and symptom may be present :.Gastrointestinal – bloating, belching, nausea, vomiting and/or regurgitation. Refer to Gastric Chest Pain.Respiratory – persistent cough, abnormal breathing sounds, difficulty breathing when lying flat, expectorating mucus or coughing up blood..Musculoskeletal – limited range of motion, cannot tolerate pressure on the affected area.Psychological – depressed, excited, agitated, fearful. Severe shortness of breath patient may report a feeling of suffocation.DizzinessFainting spells Associated Signs and Symptoms

7. Chest pain

8. Angina pectoris, is chest pain or pressure, usually due to insufficient blood flow to the heart muscle.Angina is usually due to obstruction or spasm of the coronary arteries. The main mechanism of coronary artery obstruction is an atherosclerosis.

9. Risk factors of atherosclerosis HTN, diabetes, smoking, obesity, family history, and an unhealthy diet.Plaque is made up of fat, cholesterol, calcium, and other substances found in the bloodAtherosclerosis generally starts when a person is young and worsens with ageAtherosclerosis is asymptomatic for decades .

10. The pain is usually central (towards the center of the chest) and fanning outwards (diffuse)..

11. Types of angina Four types:Stable anginaUnstable angina Microvascular anginaPrinzmetal’s angina

12. 1) Stable angina:Also called “Atherosclerotic angina or angina of effort or classic angina ”Discomfort is precipitated by activityMinimal or no symptoms at rest*This refers to the more common type {about 90% of angina cases} of angina related to myocardial ischemia. Symptoms typically abate several minutes {Rest usually leads to complete relief of the pain within 15 minutes following cessation of precipitating activitiesWhen cardiac work increases (eg, in exercise), the obstruction of flow and inadequate oxygen delivery results in the accumulation of acidic metabolites that stimulate myocardial pain endings.

13. 2)Unstable angina:-It is between stable angina and MI -also called "crescendo angina;" this is a form of acute coronary syndrome)It has at least one of these three features:1) It occurs at rest (or with minimal exertion) usually not respond to nitroglycerin.2)usually lasting >10 min;3)It is severe and of new onset (i.e., within the prior 4–6 weeks); and/or It occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than before).4) May progress to MI#Requires hospital admission and more aggressive therapy to prevent progression to MI and death .

14. 2)Unstable angina:

15. 3) Microvascular angina:Also called Syndrome X ; because it is of unknown cause Probably due to poor functioning of the small blood vessels of the heart, arms and legsSymptoms : chest pain usually lasts longer than 10 minutes, and it can last longer than 30 minutes. Pain can occur with exercise or at rest .Partially respond to nitrate.Difficult to diagnose because it does not have arterial blockage { Normal angiography however ,positive ECG with exercise test ; ST depression}Good prognosis

16. 4)Prinzmetal’s angina-Is a variant and uncommon form of angina with normal coronary vessels or minimal atherosclerosis-It is occur usually occur at morning with rest probably due to spasm of coronary artery. -More common in female-Generally responds to coronary vasodilators such as nitroglycerin and calcium channel blockers. -Use of B –blockers is contraindicationST elevation on ECG during chest pain

17. Types of angina

18. ECG in angina.ECG is useful for evaluating persons with angina pectoris; however, findings are variable among patients.Approximately 50% of patients with angina pectoris have normal findings after a resting ECG. However, abnormalities such as evidence for prior MI, intraventricular conduction delay, various degrees of atrioventricular block, arrhythmias, or ST-T–wave changes may be seen

19. ECGIn angina patients who are not feeling any one chest pain, an electrocardiogram (ECG) is typically normal. During periods of pain, depression or elevation of the ST segment may be observed OR T-wave inversion. To elicit these changes, an exercise ECG test ("treadmill test") may be performed, during which the patient exercises to their maximum ability before fatigue, breathlessness or, importantly, pain intervenes; if characteristic ECG changes are documented ..

20. Therapeutic Strategies 1) Reducing oxygen requirement Nitrates, calcium channel blockers, and the β- blockers.2) Increasing oxygen delivery . Nitrates, calcium channel blockers and revascularization .

21. Classification of anti- anginal agents1) Nitrates a. Short acting : Glyceryl Trinitrate (GTN or Angised).b. Long acting : isosorbide mononitrate and isosorbide dinitrate2) Calcium channel blockers: -Phenyl alkylamine ( verapamil act only on heart)-Benzothiazipine (diltiazim act on both heart and blood vessels )-Dihydropyridines ( nifedipine , amlodipine , nimodipine)3) Beta – blockers ( metoprolol , atenolol , propranolol)4) Potassium channel openers : nicorandil 5) Others : trimetazidine , ranoline , ivabradine.

22. 1) Organic Nitrates : prodrugs that release nitric oxide ; mainly venodilators but also cause arteriolar dilation and as a result reduces both preload and afterload .

23. Nitrates side effects1.Headache :The most common side effect of nitrates is headache due to veno-dilation, patients whom intermittently used nitrate preparation should be asked about headaches after nitrate use; lack of headache often indicates degradation of agent with a loss of therapeutic effect. 2.Postural hypotension & syncope particularly with sublingual use. 3.Tachycardia induced by decreased PVR may itself induce anginal symptoms especially with unstable symptoms. 4. Methhaemoglobinemia .

24. Drug interactions# Sildenafil { absolute contraindicated with nitrate } and other vasodilators potentiate the hypotensive action of nitrates that may resulted in MI and sudden death.Tolerance : nitrate free intervals (required 10-12hrs typically at night ; however variant angina worsens early in the morning therefore it should be used in the late afternoon).

25. 2) Calcium Channel-Blocking Drugs {Diltiazem and verapamil}.Mechanism of ActionCalcium channel blockers block voltage-gated L-type calcium channels, the calcium channels most important in cardiac and smooth muscle. By decreasing calcium influx during action potentials these agents reduce intracellular calcium concentration and muscle contractility. .

26. 3) Beta-Blocking Drugs (metoprolol, atenolol)Because they reduce cardiac work (and oxygen demand), all blockers are effective in the prophylaxis of atherosclerotic angina attacks. Effects and Clinical UseActions include (decreased heart rate, cardiac force, blood pressure) .Beta blockers are used only for prophylactic therapy of angina; they are of no value in an acute attack. They are effective in preventing exercise-induced angina but are ineffective against the vasospastic form. ..

27. The combination of blockers and nitrates is useful because the adverse undesirable compensatory effects evoked by the nitrates (tachycardia and increased cardiac force) are prevented or reduced by beta- blockers .#Patient use beta-blockers should be gradually tapered off over to 5- 10 days to avoid rebound angina..

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29. MI

30. Potassium channel openers: nicorandil

31. MI

32. Drugs used for treatment of angina pectoris ACE inhibitors are also vasodilators with both symptomatic and prognostic benefit. Statins (rosuvastatin , atorvastatin , simvastatin)  are the most frequently used lipid/cholesterol modifiers, which probably also stabilize existing atheromatous plaque.Low-dose aspirin 100mg or clopidogrel 75mg (plavix) decreases the risk of heart attack in patients with chronic stable angina, and was part of standard treatment. Anticoagulant drugs ( e.g. heparin ) are used in unstable angina.