Outpatient and Primary
Care Medicine
New NMS guidelines
2005 Edition
Paul D. Chan, MD
David M. Thomas, MD
Eric W. McKinley, MD
Elizabeth K. Stanford, MD
Current Clinical Strategies Publishing
www.ccspublishing.com/ccs
Digital Book and Updates
Purchasers of this book may download the digital book and updates for Palm, Pocket PC, Windows and Macintosh. The digital books can be downloaded at the Current Clinical Strategies Publishing Internet site:
www.ccspublishing.com/ccs/op.htm
Copyright \u00a9 2005 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced or stored in an information retrieval network without the written permission of the publisher. The reader is advised to consult the package insert and other references before using any therapeutic agent. The publisher disclaims any liability, loss, injury, or damage incurred as a conse- quence, directly or indirectly, of the use and application of any of the contents of this text.
Current Clinical Strategies Publishing
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ISBN 1929622-45-7
Cardiovascular Disorders
Stable Angina Pectoris
Angina pectoris is a symptom complex caused by myocardial ischemia. Stable angina refers to chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerin. Unstable angina includes new onset of chest pain, progressing effort angina, rest angina, post-myocardial infarction angina, and angina after revascularization.
I.Clinical evaluation
A.Important points include the following:
1.History of previous heart disease
2.Possible non-atheromatous causes of angina (eg,
aortic stenosis)
3.Symptoms of systemic atherosclerosis (eg,
claudication)
4.Severity and pattern of symptoms of angina
5.Risk factors for coronary heart disease, include
smoking, inappropriate activity level, stress, hyperlipidemia, obesity, hypertension, and diabetes mellitus.
B.Physical examinationshould include a cardiovascular
examination, evaluation for hyperlipidemia, hypertension, peripheral vascular disease, congestive heart failure, anemia, and thyroid disease.
C.Laboratory studiesshould include an electrocardiogram
and a fasting lipid profile. Further studies may include chest films, hemoglobin, and tests for diabetes, thyroid function, and renal function.
D.Exercise electrocardiography.An exercise test should
be obtained for prognostic information.
1.Sensitivity of exercise electrocardiography may be
reduced for patients unable to reach the level of exercise
required for near maximal effort, such as:
a.Patients taking beta blockers
b.Patients in whom fatigue, dyspnea, or claudication
symptoms develop
c.Patients who cannot perform leg exercises
2.Reduced specificity may be seen in patients with
abnormalities on baseline electrocardiograms, such as those taking digoxin or with left ventricular hypertrophy or left bundle branch block.
E.Noninvasive imaging,such as myocardial perfusion
scintigraphy or stress echocardiography, may be indicated in patients unable to complete exercise electrocardiogra- phy.
II.Medical treatment of stable angina pectoris
A.Nitrates
1.Nitratesare a first-line therapy for the treatment of
acute anginal symptoms. While they act as venodilators, coronary vasodilators, and modest arteriolar dilators, the primary antiischemic effect of nitrates is to decrease myocardial oxygen demand by producing systemic vasodilation more than coronary vasodilation.
2.In combination with beta blockers or calcium channel
blockers, nitrates produce greater antianginal and antiischemic effects. There is no difference in efficacy among preparations.
3.Sublingual nitroglycerin
a.Sublingual nitroglycerin (Nitrostat) is the therapy of
choice for acute anginal episodes and prophylactically
for activities known to elicit angina.
b.The initial dose is 0.3 mg. A second dose can be
taken if symptoms persist after three to five minutes.
4.Chronic nitrate therapy
a.Chronic nitrate therapy, in the form of an oral or
transdermal preparation (isosorbide dinitrate, isosorbide mononitrate, or transdermal nitroglycerin) can prevent or reduce the frequency of recurrent anginal episodes and improve exercise tolerance. Chronic nitrate therapy is a second-line antianginal therapy.
b.Isosorbide dinitrate (ISDN, Isordil SR, Dilatrate-
SR, Isordil Tembids)dosing begins with a dose of
10 mg at 8 AM, 1 PM, and 6 PM, which results in a 14 hour nitrate dose-free interval. The dose is increased to 40 mg three times daily as needed. Alternatively, isosorbide dinitrate can be taken twice daily at 8 AM and 4 PM.
c.The extended release preparation of isosorbide
mononitrate (Imdur), which is administered once per day, may be preferable to improve compliance. The starting dose is 30 mg once daily and can be titrated to 120 mg once daily as needed. Some patients may develop nocturnal or rebound angina, which requires twice daily dosing or additional antianginal therapy.
d.Transdermal nitroglycerin (Transderm-Nitro).
Use of a transdermal patch is convenient. Since most patients have angina with activity, that the patch should be applied at 8 AM and removed at 8 PM. The occasional patient with significant nocturnal angina can be treated with a patch-on period from 8 PM to 8 AM. The initial dose is 0.2 mg per hour; the dose can be increased to 0.8 mg per hour as needed.
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