Chronic stable angina medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
The goal of the management of [[Chronic stable angina definition|chronic stable angina]] is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by [[myocardial infractio]]n or development of [[heart failure]]. The mainstays of the treatment of [[chronic stable angina]] are patient education, lifestyle changes and medical therapy<ref name=" | The goal of the management of [[Chronic stable angina definition|chronic stable angina]] is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by [[myocardial infractio]]n or development of [[heart failure]]. The mainstays of the treatment of [[chronic stable angina]] are patient education, lifestyle changes and medical therapy<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref>. In patients with chronic stable angina, immediate '''symptomatic relief''' is achieved with [[Chronic stable angina nitrate therapy|short-acting sublingual nitrates]] and long term symptom relief is achieved with [[Chronic stable angina beta blocker therapy|beta blockers]] as first line therapy, or [[Chronic stable angina treatment calcium channel blockers|calcium channel blockers]] and [[Chronic stable angina nitrate therapy|long-acting nitrates]] when beta blockers are contraindicated. Drugs that improve the quality of life and are associated with a '''better prognosis''' include: [[Chronic stable angina treatment aspirin|low dose aspirin]], [[Chronic stable angina beta blocker therapy|beta-blockers]] and [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
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* To improve the quality of life: | * To improve the quality of life: | ||
** By decreasing the severity and frequency of angina | ** By decreasing the severity and frequency of angina | ||
** By increasing exercise tolerance.<ref name=" | ** By increasing exercise tolerance.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
===Management Plan=== | ===Management Plan=== | ||
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==Patient Education== | ==Patient Education== | ||
* Importance of life style changes | * Importance of life style changes | ||
* Importance of compliance to medications.<ref name=" | * Importance of compliance to medications.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Risk Factors Modification== | ==Risk Factors Modification== | ||
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====Smoking cessation==== | ====Smoking cessation==== | ||
* Strong recommendation to stop smoking.<ref name=" | * Strong recommendation to stop smoking.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Prevention of Acute Coronary Syndrome== | ==Prevention of Acute Coronary Syndrome== | ||
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*Strong consideration should be given to the initiation of '''[[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]]''' as potential disease modifying therapy. | *Strong consideration should be given to the initiation of '''[[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]]''' as potential disease modifying therapy. | ||
* [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]] should be given to almost all patients with chronic stable angina especially in the presence of [[diabetes]], [[hypertension]] or [[chronic kidney disease]]. | * [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]] should be given to almost all patients with chronic stable angina especially in the presence of [[diabetes]], [[hypertension]] or [[chronic kidney disease]]. | ||
*'''[[Chronic stable angina treatment calcium channel blockers|Calcium channel blockers]]''' should be considered in patients who cannot tolerate [[Chronic stable angina treatment beta blockers|beta blockers]] or [[Chronic stable angina treatment nitrates|nitrates]] or who respond inadequately to these drugs. However, [[Chronic stable angina treatment calcium channel blockers|CCBs]] are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release [[nifedipine]], second generation vasoselective calcium channel blockers, and extended-release [[verapamil]] or [[diltiazem]] are the calcium blockers of choice.<ref name=" | *'''[[Chronic stable angina treatment calcium channel blockers|Calcium channel blockers]]''' should be considered in patients who cannot tolerate [[Chronic stable angina treatment beta blockers|beta blockers]] or [[Chronic stable angina treatment nitrates|nitrates]] or who respond inadequately to these drugs. However, [[Chronic stable angina treatment calcium channel blockers|CCBs]] are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release [[nifedipine]], second generation vasoselective calcium channel blockers, and extended-release [[verapamil]] or [[diltiazem]] are the calcium blockers of choice.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Symptomatic Relief== | ==Symptomatic Relief== | ||
Revision as of 04:53, 21 November 2012
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina medical therapy On the Web | ||
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Risk calculators and risk factors for Chronic stable angina medical therapy | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [5]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.; Rim Halaby
Overview
The goal of the management of chronic stable angina is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by myocardial infraction or development of heart failure. The mainstays of the treatment of chronic stable angina are patient education, lifestyle changes and medical therapy[1]. In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term symptom relief is achieved with beta blockers as first line therapy, or calcium channel blockers and long-acting nitrates when beta blockers are contraindicated. Drugs that improve the quality of life and are associated with a better prognosis include: low dose aspirin, beta-blockers and ACEIs.
Medical Therapy
- Lifestyle modification and medical therapy are the first line treatment of patients with chronic stable angina.
Goals of the Medical Therapy
- To decrease premature cardiovascular death :
- By decreasing incidence of myocardial infarction and heart failure
- By increasing survival
- To improve the quality of life:
- By decreasing the severity and frequency of angina
- By increasing exercise tolerance.[1]
Management Plan
- Patient education
- Risk factor modification
- Prevention of acute coronary syndrome
- Symptomatic relief.
Patient Education
- Importance of life style changes
- Importance of compliance to medications.[1]
Risk Factors Modification
Lipid profile
- Daily physical activity
- Weight management
- Diet low in saturated fats, trans fat, cholesterol
- Pharmacotherapy with lipid lowering drug therapy ideally HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (less than 70 mg/dl in high-risk patients).
Treatment of hypertension
- Physical activity
- Moderate alcohol intake if any
- Diet low in sodium and rich in fruits, vegetables and low fat dairy products
- Pharmacotherapy with ACEIs and/or beta-blockers.
Control of diabetes
- Glycemic control.
Physical activity
- 30 to 60 minutes of moderate aerobic exercise at least five days a week.
Weight management
- Target BMI: between 18.5 and 24.9 Kg/m2
- Target waist circumference: less than 40 inches in males and less than 35 inches in females.
Smoking cessation
- Strong recommendation to stop smoking.[1]
Prevention of Acute Coronary Syndrome
Aspirin
- Aspirin (75-162 mg/day) minimizes the risk of thrombosis superimposed on the chronic fixed obstruction.
- Aspirin should be used indefinitely unless contraindicated.
- If Aspirin is contraindicated, the second line treatment is clopidogrel.
Beta Blockers
- Beta blockers reduces heart rate and myocardial oxygen demands, as well as the risk of fatal arrhythmias as a consequence of plaque rupture.
- Beta blockers have shown to prevent ischemia even with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with ischemic heart disease.
- Beta blockers should be used at least three years following myocardial infaction or acute coronary syndrome.
- If left ventricular dysfunction is present, metoprolol, carvedilol or bisoprolol should be used.
ACE Inhibitors
- Strong consideration should be given to the initiation of ACE inhibitors as potential disease modifying therapy.
- ACE inhibitors should be given to almost all patients with chronic stable angina especially in the presence of diabetes, hypertension or chronic kidney disease.
- Calcium channel blockers should be considered in patients who cannot tolerate beta blockers or nitrates or who respond inadequately to these drugs. However, CCBs are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release nifedipine, second generation vasoselective calcium channel blockers, and extended-release verapamil or diltiazem are the calcium blockers of choice.[1]
Symptomatic Relief
- The first line therapy consists of the use of beta blockers, and if the response to beta blocker therapy is inadequate, nitrates may be added.
- For immediate symptomatic relief, sublingal or spray nitroglycerine should be used.
- If angina episodes occur more than 2-3 times in a week, a calcium channel blocker or a long acting nitrate may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce blood pressure and subsequently improve ventricular function.
- In patients with special circumstances or concomitant diseases, specific medications, or combinations of medications are preferable.
- Consider adding a third agent if angina persists despite of two anti-anginal drugs.
- Coronary angiography is indicated in patients with refractory symptoms or ischemia, wherein, administration of optimal medical therapy has failed to control the symptoms or ischemia. Coronary angiography is also indicated in high-risk patients with non invasive test results, and in those with special occupations or sedentary life styles that require a more aggressive approach.
Chronic Stable Angina: Individual Pharmacologic Agents
You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic.
- Antiplatelet agents: Aspirin | Dipyridamole | Clopidogrel
- Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium channel openers | Newer Anti-anginal Agents
Related Chapters
Sources
- Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology[2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina[5]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.
- ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). %5bhttp://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf%5d "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology" Check
|url=value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367. - ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [1] PMID: 10351980
- ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[2] PMID: 12515758
- ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[3] PMID: 17998462