Outpatient and PrimaryCare Medicine
New NMS guidelines2005 Edition
Paul D. Chan, MDDavid M. Thomas, MDEric W. McKinley, MDElizabeth K. Stanford, MD
Current Clinical Strategies Publishing www.ccspublishing.com/ccs
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Copyright © 2005 Current Clinical Strategies Publishing. Allrights reserved. This book, or any parts thereof, may not bereproduced or stored in an information retrieval networkwithout the written permission of the publisher. The reader isadvised to consult the package insert and other referencesbefore using any therapeutic agent. The publisher disclaimsany liability, loss, injury, or damage incurred as a conse-quence, directly or indirectly, of the use and application of anyof the contents of this text.
Current Clinical Strategies Publishing
27071 Cabot RoadLaguna Hills, California 92653-7011Phone: 800-331-8227Fax: 800-965-9420Internet: www.ccspublishing.com/ccsE-mail: info@ccspublishing.comPrinted in USAISBN 1929622-45-7
Cardiovascular Disorders
Stable Angina Pectoris
Angina pectoris is a symptom complex caused by myocardialischemia. Stable angina refers to chest discomfort that occurspredictably and reproducibly at a certain level of exertion andis relieved with rest or nitroglycerin. Unstable angina includesnew onset of chest pain, progressing effort angina, restangina, post-myocardial infarction angina, and angina afterrevascularization.
I.Clinical evaluationA.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, includesmoking, inappropriate activity level, stress,hyperlipidemia, obesity, hypertension, and diabetesmellitus.
B.Physical examination
should include a cardiovascularexamination, evaluation for hyperlipidemia, hypertension,peripheral vascular disease, congestive heart failure,anemia, and thyroid disease.
C.Laboratory studies
should include an electrocardiogramand a fasting lipid profile. Further studies may include chestfilms, hemoglobin, and tests for diabetes, thyroid function,and renal function.
D.Exercise electrocardiography.
An exercise test shouldbe obtained for prognostic information.
1.
Sensitivity of exercise electrocardiography may bereduced for patients unable to reach the level of exerciserequired for near maximal effort, such as:
a.
Patients taking beta blockers
b.
Patients in whom fatigue, dyspnea, or claudicationsymptoms develop
c.
Patients who cannot perform leg exercises
2.
Reduced specificity may be seen in patients withabnormalities on baseline electrocardiograms, such asthose taking digoxin or with left ventricular hypertrophyor left bundle branch block.
E.Noninvasive imaging,
such as myocardial perfusionscintigraphy or stress echocardiography, may be indicatedin patients unable to complete exercise electrocardiogra-phy.
II.Medical treatment of stable angina pectorisA.Nitrates1.Nitrates
are a first-line therapy for the treatment ofacute anginal symptoms. While they act as venodilators,coronary vasodilators, and modest arteriolar dilators, theprimary antiischemic effect of nitrates is to decreasemyocardial oxygen demand by producing systemicvasodilation more than coronary vasodilation.
2.
In combination with beta blockers or calcium channelblockers, nitrates produce greater antianginal andantiischemic effects. There is no difference in efficacyamong preparations.
3.Sublingual nitroglycerina.
Sublingual nitroglycerin (Nitrostat) is the therapy ofchoice for acute anginal episodes and prophylacticallyfor activities known to elicit angina.
b.
The initial dose is 0.3 mg. A second dose can betaken if symptoms persist after three to five minutes.
4.Chronic nitrate therapya.
Chronic nitrate therapy, in the form of an oral ortransdermal preparation (isosorbide dinitrate,isosorbide mononitrate, or transdermal nitroglycerin)can prevent or reduce the frequency of recurrentanginal episodes and improve exercise tolerance.Chronic nitrate therapy is a second-line antianginaltherapy.
b.Isosorbide dinitrate (ISDN, Isordil SR, Dilatrate-SR, Isordil Tembids)
dosing begins with a dose of10 mg at 8 AM, 1 PM, and 6 PM, which results in a 14hour nitrate dose-free interval. The dose is increasedto 40 mg three times daily as needed. Alternatively,isosorbide dinitrate can be taken twice daily at 8 AMand 4 PM.
c.
The extended release preparation of isosorbidemononitrate (Imdur), which is administered once perday, may be preferable to improve compliance. Thestarting dose is 30 mg once daily and can be titratedto 120 mg once daily as needed. Some patients maydevelop nocturnal or rebound angina, which requirestwice daily dosing or additional antianginal therapy.
d.Transdermal nitroglycerin (Transderm-Nitro).
Use of a transdermal patch is convenient. Since mostpatients have angina with activity, that the patchshould be applied at 8 AM and removed at 8 PM. Theoccasional patient with significant nocturnal anginacan be treated with a patch-on period from 8 PM to8 AM. The initial dose is 0.2 mg per hour; the dosecan be increased to 0.8 mg per hour as needed.
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Outpatient Medicine
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