What is angina pectoris?

y Anginal pain is a sudden retro-sternal/ sub-sternal pain/discomfort due to transient myocardial

y y

y y

ischaemia due to narrowing or constriction of smooth muscles in the coronary arteries reduces the amount of blood carried to the heart when there is lack of blood supply to bring oxygen and nutrients to the heart, the pain of angina is felt. Commonly, the pain radiates to the left arm, occasionally to right or both arms. Usually there is an exersional or emotional component to help in diagnosis. The pain is characterized by a tightness, an ache, a pressure, a heavy feeling, constriction or frequently breathless feeling. Describing the pain with a clenched fist is a helpful sign (see figure). Some experience the pain when lying flat (decubitus angina), and some are awakened by it (nocturnal angina) The most convincing ECG evidence of myocardial ischaemia is obtained by reversible ST segment depression or elevation, with or with out T wave inversion at the time of pain induced by exercise testing Angina may also occur as a result of coronary arterial spasm accompanied by transient ST elevation on ECG (Prinz metal s or variant angina). Preinfarction angina or unstable angina is an acute coronary insufficiency characterized by worsening angina or angina at rest . Though the pain occurs at rest it is still relieved by sublingual nitrates.

Site And Radiation Of Anginal Pain

Precipitating Causes Of Angina

 Coronary artery fill in diastole, when supply and demand problem occur secondary to coronary artery disease, any factor increasing heart rate and demand at the expense of supply will induce pain.  Pain therefore follows exertion, emotion, a large meal and temperature change. Typically, the pain is present on walking, specially up hill or up stairs and is worse in cold or windy weather or soon after a meal.  The amount of exercise needed to bring on the pain can vary a lot, emotional background (dream induced angina) sexual intercourse and emotion can induce angina  A slowing of heart rate by rest and relaxation will reduce demand.  This means walking slowly, sitting down or using GTN will relieve the pain of angina

Medical management
y Four groups of drugs are used to help relieve or prevent the pain of angina:- Nitrates, beta blockers, calcium antagonists and potassium channel activators y Nitrates and nitrites act directly on smooth muscles to produce venous and arteriolar dilatation causing reduction in myocardial oxygen demand (lower preload and after load) and an increase in myocardial oxygen supply (coronary vasodilatation) y Rapidly acting preparations for the treatment of acute angina:1. Sublingual glyceryl trinitrate :(GTN) administered from a metered- dose aerosol (400 mcg per spray) or as a tablet (300 or 5000 mcg) to dissolve under the tongue will usually relieve an attack of angina in 2-3 minutes. 2. Amyl nitrite: Volatile liquid given by inhalation 3. Isosorbide dinitrate: Given as sublingual tablet similar to GTN, but has a long duration of action y GTN is subject to extensive first-pass metabolism in the liver and is there fore ineffective when swallowed y Topical nitrates also avoid liver metabolism. GTN ointment 2% (Percutol) will last upto 8 hours. The ointment begins at 1/2 inch tds doses. Dosage can be increased at 1 inch increments tds and used as sweat band around the wrist. Topical nitrates are of great value for nocturnal pain. Continuous nitrate therapy often causes pharmacological tolerance which can be avoided by using by a variety of once- daily preparations with a built in nitrate-free period and given at night when the patient is inactive. y I.V nitrates (GTN 0.6mg/hr or isosorbide dinitrate 1mg/hr) are useful in the treatment of unstable angina y Side effects: The main side effects are flushing, throbbing head ache and postral hypotension.

Management (con t)
 Beta blockers: Lower myocardial oxygen demand by reducing heart rate, blood pressure and myocardial contractility. Nonselective beta blockers may aggravate coronary spasm by blocking the coronary artery B2- adrenoceptors and is usually advisable to use a once-daily cardio selective preparation (e.g. atenolol 50-100 mg daily, SR metoprolol 200mg daily, besoprolol 5-10 mg daily).  Beta blockers shouldn t be with drawn abruptly because of danger of arrhythmias, worsening angina or MI  Side effects Are bronchospasm which aggravate asthma and heart failure and peripheral vascular disease (cold hands, feet and heavy legs) present the major problems. These symptoms reflect a fall in cardiac output. CNS side effects include night mares, drowsiness and depression  Atenolol and besoprolol are water soluble and largely excreted unchanged through the kidneys and there fore useful in the treatment of angina

Management (con t)
y Calcium antagonists: Inhibit the slow inward current

caused by the entry of extra cellular calcium through the cell membrane of cardiac arteriolar smooth muscle, and lower myocardial oxygen demand by reducing blood pressure and myocardial contractility and there fore useful in the management of angina pectoris. y Nifedipine (Adalat) nicardipine and amlodipine often cause reflex tachycardia there fore best to use in combination with beta blockers. Verapamil and diltiazem are suitable for patients not receiving a beta blocker because they inhibit AV node conduction and tend to cause bradycardia. It is of great value in patients with COPD or peripheral artery disease where beta blockers are contraindicated. y Toxicity: excessive inhibition of calcium influx can cause serious cardiac depression, including cardiac arrest, bradycardia AV block and heart failure.

Anti Anginal Medications

1: Baroreceptor reflex Note: Undesirable effects are shown in ITALICS

Calcium antagonists used for treatment of angina

Summary (cont)

Newer Investigational Drugs

Invasive Treatment Of Angina

y Invasive treatment of ischemic heart disease include coronary angioplasty called PTCA (percutaneous transluminal coronary angioplasty), reversed sapheanous vein bypass grafting and internal memory artery grafting called CABG (coronary artery bypass grafting) y Coronary angioplasty (PTCA) is an invasive technique which can be used to provide complete or partial revascularization in patients with stable and unstable angina and MI y Coronary angioplasty is an effective symptomatic treatment for chronic stable angina and is mainly used in single or 2 vessel disease, and the procedure is often used to provide palliative therapy for patients with recurrent angina after CABG y Coronary angiography is essential before performing PTCA in patients when non invasive tests fail to diagnose the cause of atypical chest pain (See diagram)

Coronary Angiography And PTCA