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Angina

Amareen Bhambra Senior Pharmacist Royal Brompton & Harefield NHS Trust

Aims and objectives


Define

term angina Understand the different management strategies Role of pharmacist

Agenda
Angina Pathogenesis Ris

factors Diagnosis !anagement Surgical re"ascularisation Secondary pre"ention

Angina
#oronary

heart disease Stable angina


$pisodes chest pain Usually predictable Physical e%ertion $motional stress

Unstable

angina

At rest Sudden

Pathogenesis
Stable

angina

Stenosed coronary artery unable to meet myocardial o%ygen demand & chest pain on e%ertion

Unstable

angina

Progression of atherosclerosis follo'ing the rupture of pla(ue

Risk factors
!odifiable

Hypertension Smo ing Hyperlipidaemia Diabetes Age Se% *amily H%

Non)modifiable

Diagnosis

Accurate clinical H% $stablish or e%clude presence +HD $#, Haemoglobin

Anaemia e%acerbate ischaemic chest pain

Thyroid function *asting glucose #holesterol

N+#$ recommends statin therapy to all high)ris patients regardless of serum cholesterol

Management of angina

Aim to relie"e symptoms and reduce #- ris

Symptom management . increase o%ygen supply by dilating coronary arteries Sublingual ,TN /acute01 beta bloc ers2long)acting nitrates2##Bs Reduce #- ris . smo ing cessation1 e%ercise1 diet1 alcohol consumption1 'eight and diabetes Pre"ent future cardiac e"ents

Choice of treatment
+nitial

management consists one or t'o antiangina drugs3 Beta bloc er2##B +f symptoms are not controlled4

5ong acting nitrate Nicorandil +"abradine Ranola6ine

Beta blockers
Reduce

heart rate1 blood pressure and contractility of myocardium Reduction myocardial o%ygen demand Reduce mortality rates Atenolol1 bisoprolol1 metoprolol

#ardioselecti"e

Calcium channel blockers


!odulate

calcium influ% into "ascular smooth muscle and myocardium & "asodilatory effect Dihydropyridines . amlodipine Ben6othiapine . diltia6em Phenylal ylamines ) "erapamil

Nitrates
,TN

Denitration releases nitric o%ide Dilatation lo'ers myocardial o%ygen re(uirements

Sublingual

,TN ,TN

Alle"iate immediate symptoms Tolerance

Transdermal

Long-acting nitrates
+SDN +S!N !R

preparations #ompliance Nitrate free period

Nicorandil
78

channel acti"ator ,radual dose titration to minimise side effects ,astrointestinal ulceration 9:mg BD

vabradine
+nhibits +f channel

in sinus node -alue in patients re(uiring reduction HR


Beta bloc ers rate)controlling ##B are #2+

5icensed chronic stable angina in adults 'ith #AD in normal SR #ombination beta bloc er HR ;<:bpm

=)>3=mg BD /?3=mg BD elderly0

Side effects4 "isual symptoms1 bradycardia

Ranola!ine
!echanism

not 'ell understood +mpro"ed diastolic function HR or blood pressure not altered Side effects . constipation1 nausea1 di66iness +nteractions . sim"astatin @>=mg BD1 after ?)A 'ee s =::mg BD1 ma% >=:mg BD

"urgical revascularisation
P#+ Poor

symptom control despite medical treatment 5ate stent thrombosis #AB, +mpro"e sur"i"al compared to medical management select cohort patients

"econdar# $revention
Aspirin Statin Beta

bloc er A#$+

Anti$latelet thera$#
Secondary >=mg

pre"ention

BD +nhibits #BC9 and T%A? pre"ents platelet acti"ation and aggregation #lopridogrel as alternati"e

"ummar#
Angina

pain . atherosclerosis $stablish #- history for accurate diagnosis !anagement .


Drug treatment Reduce modifiable ris factors

Role

of pharmacist

References
N+#$

guideline 9?<3 !anagement of stable angina $"idence)based !anagement of #oronary Heart Disease . a"ailable "ia #PP$ #linical Pharmacist . Stable angina3 Sotiris Antoniou3 Dan ?:9?3 Ben)Dor +1 Battler A3 Treatment of stable angina3 Heart3 ?::>1 E@4 F<F)F>A3