Angina /IHD

The chest pain are caused by not getting enough blood flow to the heart. Stable angina is a chest discomfort due to myocardial ischemia that is predictably reproducible at a certain level of exertion or emotional stress.

Traditional risk factors:  hypertension, ↓ high-density lipoprotein, ↑ low-density lipoprotein (LDL), smoking, diabetes, premature CAD in first-degree relatives (men <55 years old; women <65 years old)

Non-traditional risk factors:  obesity, sedentary lifestyle, chronic inflammation, abnormal ankle-brachial indices, renal disease

Goal is to detect high-risk coronary lesions where intervention would improve long-term mortality or alleviate anginal symptoms.

Assess severity – stable (class1-4)  / unstable

Investigations – FBE, EUC, Troponin, stress echo , ECG (base line and rule out old MI) , If M/Ecg changes , HTN, DM, DEC – echo —– CTCA, MRI, ICA by specialist spc cases

Significant CAD is defined as ≥50% stenosis of the left main coronary artery or ≥70% stenosis of other major coronary arteries by angiography.

  • β-Blockers: decrease myocardial oxygen demand by lowering heart rate, BP, and contractility- metoprolol, carvedilol — Side effects: bradycardia, fatigue, and sexual dysfunction predominantly in men
  • Antiplatelets: Aspirin (100mg/day) decrease risk of thrombosis- decreases risk of first MI and reduces adverse cardiovascular events in those with stable angina. Clopidrogral if CI to aspirin . Dual only after MI or PCAI
  • Nitrates: dilate systemic veins and arteries (including coronary vessels) and cause decreased preload. GTN SL. At higher doses, they decrease BP. Long-acting nitrates such as isosorbide mononitrate (30 to 240 mg daily [extended release]) can be used for angina prophylaxis.

Side effects include headache and hypotension but tend to improve with continued usage.

  • Calcium channel blockers (CCBs): cause arterial vasodilation, decreased myocardial oxygen demand, and improved coronary blood flow. Similar effectiveness to β-blockers; may be used instead of or in addition to β-blockers. Only long acting once .Nifedipine amlo, filo

Nondihydropyridine CCB-  No use verapamil diltiazem < 40% EF —— ABN-Ceylon ltd

  • Lipid-lowering agents: High-intensity statin therapy is indicated for all patients with CAD regardless of lipid levels. Statin therapy should also be strongly considered for those with high CAD risk
  • Angiotensin-converting enzyme inhibitors (ACEIs): act on the renin-angiotensin-aldosterone system to reduce BP and afterload. They also have effects on cardiac remodeling after MI.
  • Smoking cessation
  • Diet
  • Physical activity goal: 30 to 60 minutes of moderate aerobic activity, at least 5 (preferably 7) days/weeks
  • Weight management goal: BMI 18.5 to 24.9 kg/m2; waist circumference
  • BP control goal for most patients with significant CAD: <130/80 mm Hg
  • Diabetes management
  • Revascularization should be considered if optimal medical therapy is inadequate to control symptoms.
  • PCI with balloon angioplasty and/or stent placement (with drug-eluting or bare-metal stent) is performed for significant lesions. Additional techniques include laser therapy and atherectomy.
  • Current literature does not show that PCI decreases mortality or risk of MI versus aggressive medical management in those with stable angina.
  • Coronary artery bypass graft (CABG) is preferred over PCI for those with severe left main coronary stenosis, significant lesions in ≥3 major coronary arteries, and for lesions not amenable to PCI.
  • Comorbidities , Driving , occupation , immunisation