STABLE ANGINA PECTORIS

• Angina pectoris (AP) is pain caused by myocardium ischemic.

• The characterized is retrosternal pain that located almost on chest, jaw, left
shoulder until arm and ulnar side fingers.
• AP can be felt by patient as discomfort feeling on chest ,± 10 minutes, jaw, left
shoulder, back and fingers that triggered by activity, stress emotional, and
disappeared by rest and consume nitroglyserin.
• AP can be manifest as discomfort on epigastrium.
• The pain in AP is blunt like be crushed by heavy thing on chest, strong force
from inside or under diaphragm like squeezed or burst chest. Oh the worst
situation is followed by cold sweat and dyspnue.
• The pain in AP is not sharp pain. Some time patients only tell about chest
discomfort
 CHARACTERISTICS OF AP

1. The pain is affected by activity and can be trigerred by physical stress or emotional stress
2. Quantity
• The first pain is more real form a few minutes until less than 20 minutes. If more than 20
minutes and severe have to consider as unastable angina and become acute coronary
syndrome that need special care.
• The pain can be disappeared by using sublingual nitroglycerin in a few seconds until a few
minutes.
• It is not continuous pain, but it can be dissapered and arise with increasing intensity or
reduce and controlled.
• The pain which is contionus days actually is not pain from AP.
 CLASSIFICATION OF ANGINA
PECTORIS

1. Typical Angina
Must have this 3 criteria :
a. Retrosternal discomfort with pain characteristics and time based on characteristics of AP
b. Trigerred by physical activity and emotional stress
c. Reduce by resting or consuming nitrat
2. Atypical Angina
Have 2 from 3 criteria
3. Non cardiac pain
Have 1 or none from criteria
 CHEST PAIN GRADIATION FROM CANADIAN
CARDIOVASCULAR SOCIETY (CCS)

1. CCS CLASS 1
Chest pain is triggered by heavy exercise, fast walking or in a hurry
2. CCS CLASS II
There is a few limited daily activity
Chest pain is triggered by walking around two blocks, climbing up the stairs more than one floor or in a hurry, walking
uphill
3. CCS CLASS III
There is a limited daily activity
Chest pain is triggered by walking one-two blocks, climbing up the stairs for one floor.
4. CCS CLASS IV
Pain can be a rise when resting. Any activity can be trigger the pain.
DIAGNOSTIC
 ELECTTOCARDIOGRAPHY IN RESTING
TIME

This examination can making sure the pain is non cardiac pain.
Electrocardiography 12 leads typical in ST segmen changing for myocardium
ischemic.
Other electrocardiography changing such as LVH and Q patology can be a risk.
Depression ST segmen ≥1 mm is a specific sign, and tachycardia, BBB, fasicular
block that become normal when the pain is disappeared can be ischemic.
 THORAX PHOTO

• We can look if there is coroner calsification and hearth valve.

• Other sign like hearth failure, hearth valve disease, pericarditis, aneurisma and
dissection, also patient has pain because pulmonary disease.
 ELECTROCARDIOGRAPHY IN
EXERCISE

• Contraindication of this examination is acute myocard infark less than 2 days,

severe arrythmia with hemodynamic disturbance, symptomatic hearth failure,
pulmonary emboli and pulmonary infark, pericarditis and acute myocarditis,
and aorta dissection.
• Relative contraindication is left main stenosis, stenosis aorta or other
obstruction, abnormal electrolyte, hypertension with systolic >200 mmHg and
diastolic >100 mmHg, brady or tachyarytmia, hypertrofic cardiomyopathy,
UAP, and having physical difficulty for doing this examination.
 ELECTROCARDIOGRAPHY IN
EXERCISE

• The Duke Treadmill Score (DTS)

• DTS = exercise time in minutes (n)-(5x mm depression ST)-((4x index angina, non limiting) atau (8x indeks angina, limiting))
• Indeks angina
• 0 = no angina
• 1= there is angina
• 2= angina that stop stress test

Risk DTS score Morbidity in one year

Low ≥5 0,25%
Moderate 4-10 1,25%
High ≤-11 5,25%
 ECHOCARDIOGRAPHY

• If echocardiography was done in 30 minutes after angina, we probably can sess

dysfunction of myocardium segment caused by acute ischemic.
EXERCISE ELECTROCARDIOGRAPHY
WITH SCINTIGRAPHY
 EXERCISE WITH FARMACOLOGY AND
IMAGING

• This examination is alternative for exercise electrocardiography examination.

• 1. Short acting simphatomimetic, ex :
• dobutamine (increasing oxygen consumtion)
• 2. Coroner vasodilator, ex:
• Adenosyn and dypiridamol (increasing the perfusion and other part with
stenosis become decreasing the perfussion)
MANAGEMENT APS