STABLE ANGINA

PECTORIS

Dr.H.Yerizal Karani SpPD,

SpJP
FK.UNAND / Pusat Jantung
Regional RS Dr M Djamil
Padang
Definition
• Stable angina is a clinical syndrome
characterized by discomfort in the
chest, jaw, shoulder, back or arms,
typically elicited by exertion or
emotional stress and relieved by rest
or nitroglycerin. Less typically
discomfort may occur in the
epigastric area.
• Angina pectoris related with
myocardial ischaemia
Symptoms and signs

• The history is vital component in the

diagnosis of stable angina
• The characteristic of discomfort :
- location
- character
- duration
- relation to exertion
- exacerbating or relieving factors
Classification of angina severity
according to the Canadian
Cardiovascular Society
Clas Level of symptoms
s
Class I “Ordinary activity does not cause angina”.
Angina with strenuous or rapid or prolonged
exertion only
Class II
“Slight limitation of ordinary activity”. Angina on
walking or climbing stairs rapidly, walking uphill
or exertion after meals. In cold weather, when
under emotional stress, or only during the first
Class few hours after awakening.
III
“Marked limitation of ordinary physical activity”.
Angina on walking one or two block on the level
or one flight or stairs at a normal pace under
normal condition.
• It is important to distinguish patient with
unstable angina, which may present as :
1. Rest angina
2. Rapidly increasing or crescendo angina,
i.e. previously stable angina with rapid
progressive increase in severity
3. New onset angina, i.e. recent onset of
severe angina with marked limitation of
ordinary activity within 2 month of initial
presentation
Clinical Classification of
Angina
• Typical angina (definite)
1. Substernal chest discomfort with a
characteristic quality and duration that is
2. Provoked by exertion or emotional stress
and
3. Relieved by rest or NTG
• Atypical angina (probable)
Meets two of the above characteristic
• Non cardiac chest pain :
Meets one or none of the typical angina
characteristic
Differential Diagnosis of
Angina Pectoris
1. Cardiovascular :
a. Myocardial ischemia
- Coronary atherosclerosis
- Coronary vasospasm
- Congenital CAD
- Kawasaki’s diseases
- Small vessel diseases
- Microvascular angina (syndrome X )
- Systemic arterial hypertension
- Aortic valve diseases
- Pulmonary hypertension
- Cardiomyopathy
- COPD
- Cardiac amyloid
- Cardiac tumor
b. Nonmyocardial ischemia :
- Aortic dissection
- Mitral valve prolapse
- Tachycardia, bradycardia
- Palpitation
- Pericarditis
2. Thoracic-respiratory :
- Pulmonary embolism
- Pneumothorax
- Pleuritis
- Mediastinitis
- Intrathoracic malignancy
3. Gastrointestinal :
- Gastroesophageal reflux, esophagitis
- Esophageal spasm
- Esophageal rupture
- Cholecystitis, gallstone
- Peptic ulcer
- gastritis
4. Psychologic :
- Anxiety
- Hyperventilation
- Panic attack
- depression
5. Breast :
- Pendulous breast syndrome
- Brassiere syndrome
6. Neuromuscular / Skeletal :
- Chest wall pain
- Costochondritis
- Fibromyalgia
- Thoracic outlet syndrome
- Herpes zoster
- Intercostal neuralgia
- Diaphragmatic flutter
- Bursitis
- Cardiac causalgia
Risk Factors
A. Unmodified :
- Age
- Male Sex
- Family History of CAD

B. Modified :
- Hypertension
- Smoking
- Type 2 DM
- Dyslipidemia
- Obesity
- Stress
- Lack of exercise
Physical Examination
• Physical examination should be focused
on identification or exclusion of causal or
associated conditions or precipitating
factors :
1. Sign of valvular heart disease or hypertrophic
obstructive cardiomyopathy
2. Hypertension
3. Evidence of non-coronary vascular disease
4. Significant comorbid condition, particularly
respiratory pathology
5. Sign of heart failure
6. Assessment of body mass index and waist
circumference to assist in identification of
metabolic syndrome
Laboratory test
• Fasting plasma glucose
• Fasting lipid profile (total chol, LDL, HDL,
triglycerides)
• Urea and serum creatinine
• Full blood count
• In selected patient : Cholesterol
subfractions (ApoA, ApoB), homocysteine,
Lp(a), hsCRP and haemostatic abnormality
may role in selected patients
• Marker of myocardial damage such as
troponins, CKMB
• Thyroid function
Chaest X-ray
• CXR should be request with suspect :
1. Heart failure
2. Valvular disease
3. Pulmonary disease

• The presence of cardiomegali,

pulmonary congestion, atrial
enlargement and cardiac calcification
have related to prognosis
Resting Electrocardiogram
(ECG)
• All patients with suspected angina
pectoris should have ECG recorded.
• In stable angina, resting ECG is normal
• A normal resting ECG is not uncommon
event in patient with severe angina and
does not exclude the diagnostic in
ischemia
• Resting ECG abnormality, ST depression,
Q wave, left bundle branch block (LBBB),
are associated with in adverse prognosis
ECG stress testing
• The exercise ECG is the initial test for
choice to diagnose CAD and risk stratify
1. Diagnosis of CAD.
- ST segment depression during exercise
is used to define a Positive Test
- Sensitivity and specificity:68% and 77%
- False positive : LBBB, pace rhythm,
WPW syndrome, LVH, electrolyte
imbalance and during use of digitalis.
- Exercise ECG is also less sensitive in
women
2. Risk stratification
• Prognostic indicator :
- exercise capacity
- exercise induce ischemia
• Duke Treadmill Score to
identification of high and low
risk group
Stress testing in combination
with imaging
• The most establish stress imaging
techniques are echocardiography and
perfusion scintigraphy.
• Advantage of stress imaging :
1. Superior diagnostic and prognostic
performance.
2. The ability to quantify and localise
areas of ischaemia
3. Ability to provide diasnostic
information in the presence of the ECG
abnormalities or inability of the
patient to exercise
• Stress imaging techniques :
a. Previous PCI
b. Previous CABG

• Stress echocardiography
a. More sensitive and specific than
exercise testing for the detection CAD.
b. Effectively to risk stratify patients.
Echocardiography

• In stable angina, echocardiography

to assess :
a. Valvular heart disease.
b. Ventricular function.
c. Regional wall motion
Coronary Arteriography

• A gold standard to identify the

presence or absence of
coronary lumen stenosis
Treatment

• Aims of treatment :
1. To improve prognosis by
preventing myocardial infarction
and death
2. To minimize or abolish symptoms
General Management
1. Patients and their close associates should be informed of the nature of
angina pectoris, and the implications of the diagnosis and the
treatments that may be recommended
2. Advice should be given for the management of an acute attack, i.e. to
rest, at least briefly, from the activity that provoke the angina and the
use of sublingual nitrate for acute relief of symptoms.
3. The patient should be informed of potential side-effect of nitrate and
appropriate prophylactic use of nitrate.
4. Patients should be informed of the need to seek medical advice if
angina symptoms persist for > 10-20 minutes after rest and or is not
relieved by sublingual nitrate.
5. Cigarette smoking should be strongly discouraged
6. Patients should be advised to adopt a “Mediterranean” diet with
vegetables, fruit, fish, and poultry being the mainstays. A weight
reducing diet should be recommended if the patient is overweight.
7. Alcohol in moderation maybe beneficial but excessive consumption is
harmful.
8. Fish oil rich in omega-3 fatty acids a
recommended at least once weekly.
9. Physical activity within the patients limitation
should be encouraged.
10. Concomitant disorders such as diabetes and
hypertension should be managed appropriately
11. Anaemia or hyperthyroidsm, if present should be
corrected.
12. Sexual intercourse may trigger angina.
Nitroglyserin prior to intercourse may be helpful.
Pharmacological
therapy
1. Antithrombotic drugs :
- Aspirin 75-150mg
- Clopidogrel 75mg as an
alternative
- Anticoagulant drugs (warfarin) in
high risk patient.
2. Lipid lowering drugs
3. ACE-inhibitors
4. Beta-blockers
Percutaneous Coronary
Interventions (PCI)
• PCI maybe considered for relief
of symptoms (angina pectoris,
dyspnoea, need for
rehospitalization and limitation
on exercise capacity
Coronary Artery bypass
Surgery (CABG)
• There are 2 main indication of
CABG :
1. Prognostic (reduction of
cardiac mortality and
myocardial infarction)
2. Reduce symptoms (angina
and ischemia )