‫كلية الطب والجراحة‬

Chronic Stable angina

updated by: dr. Adel Shabana

Atherosclerosis
and risk factors
 ILOS OF THIS LECTURE
 Identify the major (modifiable and non-modifiable) risk factors for
ischemic heart disease.
 Describe the management of modifiable risk factors
 Explain the pathophysiology of myocardial ischemia as a
manifestation of IHD
• Ischemic heart disease (IHD) (or
coronary heart disease) is an
imbalance in coronary oxygen demand
and supply resulting from insufficient
blood flow. In nearly all cases, the
reduction in blood flow is caused by
coronary atherosclerotic disease.
• As part of a systemic process that
involves all arteries in the body, it is an
insidious process that begins in early
adulthood with fatty streaks, these
lesions progress into plaques and
thrombus formation in middle age.
When the atherosclerotic
plaque ruptures, there is
superimposed thrombus
formation that acutely
occludes the artery; this
is the most common
cause of life-threatening
acute coronary
syndromes. (as opposed
to chronic stable angina)
 Chronic stable angina

Acute coronary syndrome

 Chronic Stable Angina :chronic coronary
syndrome
As stated earlier, myocardial ischemia can be caused by increased myocardial
oxygen demand, reduced myocardial oxygen supply, or both.
In the presence of coronary obstruction, an increase of myocardial oxygen
requirements caused by exercise, tachycardia, or emotion leads to a transitory
imbalance. (This condition is responsible for most episodes of chronic stable angina.).
In other situations, the imbalance is caused by acute reduction of oxygen
supply secondary to marked reduction or cessation of coronary flow as a result of
platelet aggregates or thrombi. This condition is responsible for most cases of Acute
coronary syndromes (ACS)
 Clinical picture:
•Site: Substernal
•Type: tightness or heaviness or
pressure
•Duration: lasting 5–15 minutes.
•Radiation: to the jaw, neck,
shoulders, or arms.
•Anginal pain is not affected by
respiration or by position.
•Provoked by: exertion
•Relieved by: rest and sublingual
nitrate
 •In certain patients (e.g. women, the elderly, and diabetics) symptoms
other than pain may occur  . “angina equivalent.”
• • “Sharp” or “knife-like” chest pain and pain which the patient can
pinpoint to an “exact area” are less likely to be related to ischemia or
infarction, especially if the chest pain is reproduced by changes in position
or palpation.
• • Response of chest pain to nitroglycerin (within a few minutes) is most
consistent with transient ischemia, but also with esophageal spasm. Chest
pain that worsens with nitroglycerin sometimes occurs with
gastroesophageal reflux disease.
• The physical exam is usually normal. A new S4 may be heard, suggesting a
stiff ventricle due to ischemia.
The Canadian Cardiovascular Society (CCS) Classification ‫هام‬
‫جدا جدا‬

It is used to determine the functional impairment of the

patient and quantify response to therapy

• Class I: Angina occurs on more than ordinary activity

• Class II: Angina on ordinary activity
• Class III: Angina on less than ordinary activity
• Class IV: Angina at rest
 ECG:
Most patients with angina will have ECG changes during an attack.

Most commonly, ST segment depression with or without T wave inversion.

Normal ECG does not rule out ischemia

Echocardiography:
It can assess for LV systolic and diastolic function,
evidence of hypokinesia, valvular abnormalities,
old infarction and myocardial or pericardial
disease, but may be normal in stable angina
patients
So, what to do…..?
• The patient is having exertional chest pain
but his resting ECG and echo are normal
>>>>>

EXERCISE HIM
 Exercise Stress Test:
• The exercise stress test (EST) (treadmill test) is a useful test
for evaluating the cause of chronic chest pain when there is
concern about IHD (stable angina). The test provides a
controlled environment for observing the effects of increases
in the myocardial demand for oxygen.
• To do an appropriate and accurate analysis, a target heart
rate must be reached. Target heart rate is 85% of predicted
maximum heart rate: (220 – patient’s age) unless test had
to be stopped before reaching that level e.g. severe chest
pain, dizziness or fatigue or significant ECG changes
• Significant fixed stenoses (>50%) of the coronary arteries
will result in ECG evidence of ischemia.
• Low-grade stenoses (<50%) may not produce sufficient
impairment of blood flow to affect the ECG; in these cases
the stress test will be normal.
 •An EST is considered positive for myocardial ischemia when chest
pain and /or ST-segment depressions occur.
•In general, the earlier the angina or ECG abnormalities occur, the
more significant they will be.
•The exercise stress testing can help to do the following:
1) Diagnose ischemic heart disease or residual ischemia after infarction
2) Determine the severity of IHD and the need for further intervention
3) Assess the effectiveness of treatment
4) Determine functional capacity e.g. for fitness to work or for cardiac
rehabilitation program.
 •EST is contraindicated when it may place the patient at
increased risk of cardiac instability, e.g., aortic dissection, ACS, or
symptomatic supraventricular arrhythmia.
•Patients who are unable to exercise or walk should be
considered for pharmacological stress testing, such as
dipyridamole (Persantine) or dobutamine stress test.
•Presence of baseline ECG abnormalities [e.g. Bundle branch
block, left ventricular hypertrophy, digoxin therapy or with a
pacemaker] may make it more difficult to interpret test results. In
those cases, patients should be evaluated by nuclear stress
imaging instead of the exercise stress test.
Certain medications require special
consideration when the test is done for
diagnosis of ischemia:
 Beta blockers may blunt the heart rate during
exercise and thus should be held 24 hours
prior to the test.
 Hold nitrates 24 hr. before the test
The sensitivity and specificity of EST is
not very high. Thus the choice to perform
this test or other more accurate tests
requires proper clinical and ECG assessment
before deciding what test to use.. e.g. Exercise
testing in asymptomatic young women yields an increased
number of false-positive results, while exercise testing in
patients with known CAD may result in an unacceptably high
false-negative rate. Thus, we must choose which patient is
eligible for doing the test.
 Other types of stress tests include:
 Nuclear stress test:
• A scanning of the heart is done at rest and after exercise, through injection of radioactive material that is
uptaken by myocardial cells if perfusion is normal.
• Nuclear testing has higher sensitivity and specificity than regular stress test and is NOT affected by baseline
changes in ECG
• In those who cannot walk, pharmacological nuclear stress test can be used: a drug [(such as dipyridamole
(persantin)] is given to induce tachycardia, or redistribution of coronary blood flow as if the person were
exercising. Do not give if the patient is wheezing.

 Dobutamine or adenosine stress test: used in those who are unable to exercise; a drug
is given to induce tachycardia, as if the person were exercising “Do not give adenosine if
the patient is wheezing”

 Stress echocardiogram: combines a treadmill stress test and an echocardiogram; the

latter can recognize abnormal movement of the walls of the left ventricle (wall motion
abnormalities) that are induced by exercise
N.B. CT coronary angiography, cardiac MRI and invasive testing
(angiography) can be used when noninvasive tests are contraindicated
or inadequate, or after a positive conventional stress test to identify
whether patient will benefit from stent placement or bypass surgery.
 Treatment:
The aims of pharmacological management of CCS patients are to:

(1) Reduce angina symptoms & exercise-induced ischemia

(2) Prevent cardiovascular events.
Life style changes  very important
Mediterranean Diet

“we are Mediterranean country but???”

 Symptom Relief:
During chest pain attacks  nitroglycerin (NTG) sublingual tablets or
spray (will alleviate pain within a few minutes)

o long-acting nitrates (nitrates must have a nitrate-free

period of 8–12 hours (overnight) to prevent tachyphylaxis)
o Beta blockers or Calcium channel blockers (if there is
severe reactive airway disease).
o Add ranolazine (monitor for QT prolongation), Nicorandil or
Trimetazidine if no response with BBs, CCBs, and nitrites.
 Prevention of attacks:
 Unless contraindicated, the two most important medications are:
o Aspirin (reduces risk of stroke, MI, death) and
o High-intensity statins (remember the LDL goal??)
o In addition, ACE inhibitors (or ARBs) are recommended if a
patient has other conditions (e.g. heart failure, hypertension, or diabetes)
or in patients at very high risk of cardiovascular events

 Evaluate severity of IHD (cardiac angiography or stress testing)

and whether revascularization (stent or bypass surgery) would be
helpful
• Every effort should be made to ensure that patients with CAD
receive optimal lipid therapy. Statins are strongly supported as
first-line medications due to compelling evidence of mortality
reduction. If patients are intolerant to a statin, consider other
statins in reduced doses. If high dose statins did not produce the
target LDL level, ezetimibe, and later on PCSK9 inhibitors can be
added.
• Better medical therapy with aspirin, beta blockers, ACE
inhibitors, and statins are decreasing the need for all
revascularization procedures.
• Beta-blocker dose must be adjusted to achieve a resting HR of
60/min
•Revascularization procedures include coronary artery bypass grafting (CABG) and
percutaneous coronary intervention (PCI).
 In Stable angina: medical management first; if symptoms persist, consider PCI or CABG

)In Acute coronary syndrome: PCI or CABG in addition to medical treatment(

*CABG is preferred for the following patients:

• Patients whose survival will be improved over medical therapy or PCI, e.g., patients
with left main disease or triple-vessel disease
• Diabetics especially with low EF

CABG involves the construction of ≥1 graft between the arterial and coronary
circulations. (Many patients receive both arterial and venous grafts.) Long-term graft
patency is significantly better with the arterial grafts (e.g., internal mammary artery).
Potential consequences of graft failure (loss of patency) include the development of
angina, myocardial infarction, or cardiac death.
• PCI involve dilating the lesion by balloon then putting a stent to
prevent re occlusion at the lesion. Because stent is a foreign material,
the patient needs dual antiplatelet therapy for several months to
avoid thrombus formation at the stent site, till endothelial lining
occurs.
 CLINICAL RECALL
Which of the following is most likely to decrease a
patient’s risk for developing ischemic heart disease?
A. Tight glycemic control of patients with DM
B. Aggressive treatment of HTN
C. Aggressive treatment of hyperlipidemia
D. Smoking cessation
E. All of the above

Which of the following medications must be

withheld before an exercise stress test?
F. Clopidogrel
G. Metoprolol
H. Nimodipine
D. Aspirin
E. Lisinopril
Good Luck