Chronic stable angina overview

Revision as of 19:22, 28 September 2011 by Kristin Feeney (talk | contribs)
Jump to navigation Jump to search

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

Home

Patient Information

Overview

Historical Perspective

Classification

Classic
Chronic Stable Angina
Atypical
Walk through Angina
Mixed Angina
Nocturnal Angina
Postprandial Angina
Cardiac Syndrome X
Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

Pathophysiology

Epidemiology and Demographics

Risk Stratification

Pretest Probability of CAD in a Patient with Angina

Prognosis

Diagnosis

History and Symptoms

Physical Examination

Test Selection Guideline for the Individual Basis

Laboratory Findings

Electrocardiogram

Exercise ECG

Chest X Ray

Myocardial Perfusion Scintigraphy with Pharmacologic Stress

Myocardial Perfusion Scintigraphy with Thallium

Echocardiography

Exercise Echocardiography

Computed coronary tomography angiography(CCTA)

Positron Emission Tomography

Ambulatory ST Segment Monitoring

Electron Beam Tomography

Cardiac Magnetic Resonance Imaging

Coronary Angiography

Treatment

Medical Therapy

Revascularization

PCI
CABG
Hybrid Coronary Revascularization

Alternative Therapies for Refractory Angina

Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina

Discharge Care

Patient Follow-Up
Rehabilitation

Secondary Prevention

Guidelines for Asymptomatic Patients

Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

Landmark Trials

Case Studies

Case #1

Chronic stable angina overview On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic stable angina overview

CDC onChronic stable angina overview

Chronic stable angina overview in the news

Blogs on Chronic stable angina overview

to Hospitals Treating Chronic stable angina overview

Risk calculators and risk factors for Chronic stable angina overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

  • Angina pectoris, commonly known as angina, is chest pain [1] due to ischemia (a lack of blood and subsequent lack of oxygen supply) of the heart muscle. It is most often due to obstruction or spasm of the coronary arteries (the heart's blood vessels).
  • Coronary artery disease, also referred to as atherosclerosis of the coronary arteries, is the most common cause of angina. The term derives from the Greek ankhon ("strangling") and the Latin pectus ("chest") meaning "a strangling feeling in the chest".
  • In angina pectoris, symptomatic onset may include chest discomfort indicated by a feeling of tightness, heaviness, or pain in the chest cavity.

Pathophysiology

Chronic stable angina results from one of three pathophysiologic processes:

  • Most commonly, chronic stable angina is due to fixed obstructive disease or atherosclerosis which involves the narrowing of the coronary arteries.
  • This narrowing results in an inadequate supply of blood and oxygen to meet the demands of myocardial metabolism. This supply/demand mismatch activates a molecular cascade of events that causes the release of molecules such as bradykinin and adenosine, which in turn stimulate the sympathetic and vagal afferent fibers, causing anginal pain.
  • Certain conditions can increase the myocardial oxygen demand secondary to an increase in cardiac output and can exacerbate chronic stable angina. These conditions include, but are not limited to; fever, thyrotoxicosis, anemia, emotional stress, and tachyarrythmias. This increase in cardiac demand is often treated with pharmacologic intervention of beta blockers or by intervention directed towards the underlying condition.
  • Chronic stable angina can also result from microvascular disease, known as microvascular angina or Syndrome X. Microvascular angina is often treated with calcium channel blockers to relieve the spasm.

Clinical presentation

The majority of patients present with history of either, chest pain or discomfort categorized as: typical or atypical. Typical presentation would include pain or discomfort in the front or anterior precordium. Atypical presentation can be more convoluted in presentation and involve a wide range of symptoms. For example, an atypical patient may present with dyspnea instead of chest pain and this is termed an angina equivalent.

In addition to the historical presentation of chest pain or discomfort, the patient history should be extensively evaluated to include an assessment of cardiovascular risk factors. Physical examination may be normal or asymptomatic. In some cases, a physical examination may reveal heart failure. Additional findings can be important in understanding the onset of the condition. For instance, the presence of peripheral vascular disease may be associated with an increased risk of coronary artery disease (CAD).

Pretest probability of Coronary Artery Disease

Pretest probability is the probability of a given disorder before the result of the diagnostic test(s) are known. In the case of angina, the initial history and physical examination can help categorize the patient into a low, intermediate or high probability group. Assessment of the pretest probability of disease aids in the selection of diagnostic studies and in the initiation of treatment.

Diagnostic tests

Initial Studies

  • The goal of initial testing is to exclude the presence of an acute coronary syndrome such as ST elevation MI, non ST elevation MI and unstable angina. Therefore, an electrocardiogram is performed in the patient who first presents with chronic stable angina.
  • The EKG may be normal in the majority of cases if ischemia is not present at the time the EKG is obtained.
  • Other relevant findings would include evidence of left ventricular hypertrophy, or Q waves in multiple leads suggestive of old MI.

Exclusion of Factors That Would Exacerbate A Supply Demand Mismatch

In the patient who first presents with unstable angina a hemoglobin, hematocrit, and TSH should be obtained to exclude factors that would exacerbate a supply demand mismatch.

Studies to aid in the Management of Chronic Risk Factors

This includes lab tests like a lipid profile and the assessment of the Hb a1C and glucose.

Imaging Studies and Studies to Assess the Magnitude of Ischemia

Diagnostic Criteria

To confirm or qualify for the diagnosis of chronic stable angina, at least one of the following additional criteria for coronary artery disease and/or ischemia must be present:

  • New and/or dynamic ST-depression >0.05 mV, ST-elevation >0.1 mV, or symmetric T wave inversion >0.2 mV on a resting ECG
  • Definite evidence of ischemia on stress echocardiography, myocardial scintigraphy (e.g. an area of clear reversible ischemia), or ECG-only stress test (e.g., significant dynamic ST shift, horizontal or downsloping)
  • Angiographic evidence of epicardial coronary artery stenosis of >70% diameter reduction and/or evidence for intraluminal arterial thrombus.

Treatment

  • Treatment for chronic stable angina includes:
  • Smoking cessation counseling, diet and weight management, promoting physical exercise, blood pressure and diabetes control are all components of risk factor modifications and should be stressed at each clinic visit.
  • Coronary revascularization is recommended when optimal medical therapy has failed to reduce symptoms or severe atherosclerotic disease or high risk criteria on noninvasive testing [3].
  • Options available for revascularization include: percutaneous coronary intervention PCI and coronary artery bypass grafting CABG.
  • In patients with chronic stable angina, the factors influencing the choice of coronary revascularization therapy (percutaneous coronary intervention or coronary artery bypass surgery) are varied and complex. The severity of symptoms, lifestyle, extent of objective ischemia, and underlying risks must be weighed against the benefits of revascularization and the patient’s preference, as well as local availability and expertise.
  • Evidence from randomized trials and large revascularization registers can guide these decisions.
  • In the past decade there has been significant improvements in medical treatment, bypass surgery and percutaneous coronary intervention.

Prognosis of Chronic Stable Angina

Ischemic heart disease remains as the number one cause of mortality in developed countries. The prognosis of stable angina varies widely depending on severity of symptoms, extent of atherosclerosis and presence of other risk factors and co-morbidities. The presence of impaired left ventricular function is associated with a poor prognosis.

References

  1. "MerckMedicus : Dorland's Medical Dictionary". Retrieved 2009-01-09.
  2. 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). Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV; American College of Cardiology; American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2003 Jan 1;41(1):159-68. No abstract available. PMID: 12570960
  3. 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. Fraker TD Jr, Fihn SD; 2002 Chronic Stable Angina Writing Committee; American College of Cardiology; American Heart Association, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. J Am Coll Cardiol. 2007 Dec 4;50(23):2264-74. No abstract available. Erratum in: J Am Coll Cardiol. 2007 Dec 4;50(23):e1. Pasternak, Richard C [removed]. PMID: 18061078


Template:WikiDoc Sources