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This lecture was conducted during the Nephrology Unit

Grand Ground by Medical Student rotated under Nephrology
Division under the supervision and administration of Prof.
Jamal Al Wakeel, Head of Nephrology Unit, Department of
Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the
Department of Medicine. Nephrology Division is not
responsible for the content of the presentation for it is
intended for learning and /or education purpose only.
Angina Pectoris
N.A.N 2009
Presented by:
Nasrullah Nasrullah
Medical Student
February 2009
Objective
• Definition of angina.
• Types of angina.
• Classification of angina.
• Causes.
• Most risk factors.
• Investigation.
• Treatment in general.
• Summury.


N.A.N 2009
Definition of Angina Pectoris
• is the result of myocardial ischemia caused by an
imbalance between myocardial blood supply and
oxygen demand.
• Angina is a common presenting symptom
(typically, chest pain) among patients with
coronary artery disease.
• Angina pectoris is more often the presenting
symptom of coronary artery disease in women than
in men.
• Increase with age
N.A.N 2009
Types of angina
1. Stable angina.
2. Unstable angina
N.A.N 2009
Stable angina
• is that occurs when coronary perfusion is
impaired by fixed or stable atheroma of
coronary arteries.
• Ex. Pt. has fixed capacity of exertion after
he starts feeling chest pain.


Unstable angina
• is that characterized by rapidly worsening
chest pain on minimal exertion or at rest.
• = ulcerated atheroma+ thrombus
formation>>> reduction of coronary blood
flow caused by thrombus>> angina at rest
Unstable angina
• Recent onset (less than 1 month).
• Increase frequency and duration of episode.
• Angina at rest not responding readily to
therapy.
• If the pain more than 30 min.????
• MI
Stable Angina Classification
• Exertional
• Variant or Prinzmetal’s Angina
• Anginal Equivalent Syndrome
• Syndrome-X
• Silent Ischemia
• Decubitus angina
• Noctural angina
N.A.N 2009
Exertional or classical
• It occurs due to increase myocardial oxygen
demand during exertion or emotion in a
patient of narrow coronary arteries. It
relieved by rest and nitroglycerine.
• Coronary artery obstructions are not
sufficient to result in resting myocardial
ischemia. However, when myocardial
demand increases, ischemia results.
N.A.N 2009
Variant or Prinzmetal’s Angina
• Transient impairment of coronary blood
supply by vasospasm or platelet aggregation
• Majority of patients have an atherosclerotic
plaque
• Generalized arterial hypersensitivity
• Long term prognosis very good

N.A.N 2009
Prinzmetal’s Angina
• Spasm of a large coronary artery
• Transmural ischemia
• ST-Segment elevation at rest or with
exercise
• More prolonged than in classical angina.
• It occurs more in women under age 50.
N.A.N 2009

Anginal Equivalent Syndrome
• Patient’s with exertional dyspnea rather than
exertional chest pain
• Caused by exercise induced left ventricular
dysfunction
N.A.N 2009
Syndrome X
• Typical, exertional angina with positive
exercise stress test
• Anatomically normal coronary arteries
• Reduced capacity of vasodilation in
microvasculature
• Long term prognosis very good
• Calcium channel blockers and beta blockers
effective
N.A.N 2009
Silent Ischemia
• Very common
• More episodes of silent than painful
ischemia in the same patient
• Difficult to diagnose
• Holter monitor
• Exercise testing
N.A.N 2009
Holter monitor

N.A.N 2009
Decubitus angina
• Occurs when pt. lies down.
• Usually ass. With impaired LV function.
• Pt usually has severe CAD when pt, has
these symptoms,
N.A.N 2009
Noctural angina
• It awakes the pt. from sleep,
• It may provoked by vivid dreams.
• It may occur due to CAO or coronary spasm
N.A.N 2009
The Canadian Cardiovascular Society
grading scale
• is used for classification of angina severity, as follows:

• Class I : Angina only during strenuous or prolonged physical
activity
• Class II : Slight limitation, with angina only during vigorous
physical activity
• Class III : Symptoms with everyday living activities, ie, moderate
limitation
• Class IV : Inability to perform any activity without angina or
angina at rest, ie, severe limitation
N.A.N 2009
The New York Heart Association
classification
• is also used to quantify the functional limitation imposed by
patients' symptoms, as follows:

• Class I : No limitation of physical activity (Ordinary physical activity
does not cause symptoms.)
• Class II : Slight limitation of physical activity (Ordinary physical activity
does cause symptoms.)
• Class III : Moderate limitation of activity (Patient is comfortable at rest,
but less than ordinary activities cause symptoms.)
• Class IV : Unable to perform any physical activity without discomfort,
therefore severe limitation (Patient may be symptomatic even at rest.)

N.A.N 2009
Causes:
• Decrease in myocardial blood supply due to increased
coronary resistance in large and small coronary
arteries:
1. Significant coronary atherosclerotic lesion in the large epicardial
coronary arteries (ie, conductive vessels) with at least a 50%
reduction in arterial diameter
2. Coronary spasm (ie, Prinzmetal angina)
3. Abnormal constriction or deficient endothelial-dependent relaxation
of resistant vessels associated with diffuse vascular disease (ie,
microvascular angina)
4. Syndrome X
5. Systemic inflammatory or collagen vascular disease, such as
scleroderma, systemic lupus erythematous, Kawasaki disease,
polyarteritis nodosa, and Takayasu arteritis
N.A.N 2009
Cause cont.
• Increased extravascular forces, such as severe LV
hypertrophy caused by hypertension, aortic stenosis, or
hypertrophic cardiomyopathy, or increased LV diastolic
pressures
• Reduction in the oxygen-carrying capacity of blood, such as
elevated carboxyhemoglobin or severe anemia (hemoglobin,
<8 g/dL)
• Congenital anomalies of the origin and/or course of the major
epicardial coronary arteries
N.A.N 2009
Causes cont.
• Structural abnormalities of the coronary
arteries
1. Congenital coronary artery aneurysm or
fistula
2. Coronary artery ectasia
3. Coronary artery fibrosis after chest radiation
4. Coronary intimal fibrosis following cardiac
transplantation
N.A.N 2009
Risk factors:
• Major risk factors for atherosclerosis: like family
history of premature CAD, cigarette
smoking,DM,hypercholesterolemia(Metabolic
syndrome), or systemic HTN
• Other risk factors: These include LV hypertrophy,
obesity,
N.A.N 2009
Precipitating factors:
• These include factors such as severe
anemia, fever, tachyarrhythmias,
catecholamines, emotional stress, and
hyperthyroidism, which increase
myocardial oxygen demand.
N.A.N 2009
Preventive factors:
• Factors associated with reduced risk of
atherosclerosis are a high serum HDL
cholesterol level, physical activity,
estrogen, and moderate alcohol intake (1-
2 drinks/d).
• ???!! Plz Don’t drink and smoke 4u life.

N.A.N 2009
Stable Angina
Evaluation of LV Function
• Physical exam
• CXR
• Echocardiogram

N.A.N 2009
Stable Angina
Evaluation of Ischemia
• History
• Baseline Electrocardiogram
• Exercise Testing
N.A.N 2009
CCSC Angina Classification
• Class I

• Class II

• Class III

• Class IV
• Angina only with
extreme exertion
• Angina with walking
1 to 2 blocks
• Angina with walking
1 block
• Angina with minimal
activity
N.A.N 2009
ECG
• ST segment depression with or without T
wave inversion that reverse after ischemia
disappears.


N.A.N 2009
ECG
• Elevation of ST segment in prinzmental’s
angina.

N.A.N 2009
ECG
• The resting ECG may be normal between
attacks however it may show old MI, heart
block or LVH
N.A.N 2009
Stable Angina
Exercise Testing
• The goal of exercise testing is to induce a
controlled, temporary ischemic state during
clinical and ECG observation

N.A.N 2009
Angina: Exercise Testing
High Risk Patients
• Significant ST-segment depression at low
levels of exercise and/or heart rate<130
• Fall in systolic blood pressure
• Diminished exercise capacity
• Complex ventricular ectopy at low level of
exercise
N.A.N 2009
Angina: Exercise Testing
Low Risk Group
CASS Registry: 7 year survival
• Less than 1 mm ST depression in Stage III
of Bruce Protocol
• Annual mortality: 1.3%


JACC 1986;8:741-8
N.A.N 2009
Exercise Testing
Contraindications
• MI—impending or acute
• Unstable angina
• Acute myocarditis/pericarditis
• Acute systemic illness
• Severe aortic stenosis
• Congestive heart failure
• Severe hypertension
• Uncontrolled cardiac arrhythmias

N.A.N 2009
Stable Angina
Stress Echo
• Ischemia may cause wall motion abnormalities, no
rise of fall in LVEF ( left ventricular ejection fraction )






• This formula gives one a fraction, e.g., 0.60. Multiply this fraction by 100 gives a % figure, e.g., 60%

• Sensitivity/specificity same as nuclear testing


N.A.N 2009
Cardiac Catheterization
Indications
• Suspicion of multi-vessel CAD
• Determine if CABG/PTCA feasible
• Rule out CAD in patients with
persistent/disabling chest pain and
equivocal/normal noninvasive testing

• percutaneous transluminal coronary angioplasty
• coronary artery bypass grafting
N.A.N 2009
Angina: Treatment Goals
• Feel better
• Live longer
N.A.N 2009
Stable Angina
Treatment Options
Medicine Percutaneous
Intervation
CABG
Angina
Treatment Options
N.A.N 2009
Stable Angina
Non-Invasive Evaluation
Coronary Arteriography
LV Dysfunction
Coronary Arteriography
High Risk
Medical Therapy
Stable
Coronary Arteriography
Recurrent Angina
Medical Therapy
Low Risk
Stress Testing
Normal LV Function
Resting LV Function
(Clinical Assessment)
Nondisabling Angina
N.A.N 2009
Stable Angina
Treatment Options
• Medical Treatment
N.A.N 2009
Stable Angina
Current Pharmacotherapy
• Beta-blockers
• Calcium channel blockers
• Nitrates
• Aspirin
• Statins
• ? ACE inhibitors
N.A.N 2009
Stable Angina
Considerations when Choosing a Drug
• Effect on myocardium
• Effect on cardiac conduction system
• Effect on coronary/systemic arteries
• Effect on venous capitance system
• Circadian rhytm
N.A.N 2009
Reference
• Medical diagnosed and mangement 8
th
2006 ,mohammed
Danish
• OHCM 7
th

• 250 cases in clinical examination.
• pocket clincal medicine 3nd. Kumar & Clark
• http://www.ncbi.nlm.nih.gov/
• http://emedicine.medscape.com/article/150215-overview
• http://www.heartfailurematters.org
• http://health.allrefer.com/
• Ect…..

N.A.N 2009
THANKS 4 HEARING MY
PRESENTATION
I hope that it is useful
My best regards
NASRULLAH NASRULLAH (N.A.N)