treatment strategy of chronic stable angina n.
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Treatment Strategy Of Chronic Stable Angina

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Treatment Strategy Of Chronic Stable Angina

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  1. Treatment Strategy Of Chronic Stable Angina

  2. Angina: Treatment Goals Feel better Live longer

  3. The Goals of Therapy in CAD To improve quality of life (symptoms) To reduce mortality To reduce morbidity To reduce progression of disease and induce regression.

  4. Angina: Prognosis Left ventricular function Number of coronary arteries with significant stenosis Extent of jeoporized myocardium

  5. Stable Angina Risk stratification • Noninvasive testing • Cardiac catheterization

  6. Stable AnginaEvaluation of LV Function • Physical exam • CXR • Echocardiogram

  7. Stable AnginaEvaluation of Ischemia History Baseline Electrocardiogram Exercise Testing

  8. CCSC Angina Classification • Class I • Class II • Class III • Class IV • Angina only with extreme exertion • Angina with walking 1 to 2 blocks • Angina with walking 1 block • Angina with minimal activity

  9. Stable AnginaNon-Invasive Evaluation

  10. Cardiac CatheterizationIndications

  11. Risk Factor Modification Hypertension Smoking Dyslipidemia Diabetes Mellitus Obesity Stress Homocysteine

  12. Treatment of Chronic Stable Angina Medical Revascularization PCI ACBG

  13. Stable AnginaTreatment Options Medical Treatment

  14. MEDICAL THERAPY ANTIPLATELETS BETA BLOCKERS NITRATES CALCIUM ANTAGONIST ACEI STATINS NEW THERAPIES

  15. Stable AnginaConsiderations when Choosing a Drug Effect on myocardium Effect on cardiac conduction system Effect on coronary/systemic arteries Effect on venous capitance system Circadian rhytm

  16. Pharmacotherapy for Chronic Stable Angina (class I) 1. Aspirin in the absence of contraindications A  2. Beta-blockers as initial therapy in the absence of contraindications in patients with prior myocardial infarction or without prior myocardial infarction A,B  3. ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic dysfunction A  4. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol >130 mg/dl, with a target LDL of <70 mg/dl A  5. Sublingual nitroglycerin or nitroglycerin spray for the immediate relief of angina B  6. Calcium antagonists†or long-acting nitrates as initial therapy for reduction of symptoms when beta blockers are contraindicated B  7. Calcium antagonists † or long-acting nitrates in combination with beta blockers when initial treatment with beta blockers is not successful B  8. Calcium antagonists † and long-acting nitrates as a substitute for beta blockers if initial treatment with beta blockers leads to unacceptable side effects

  17. Pharmacotherapy for Chronic Stable Angina (class IIa) • 1. Clopidogrel when aspirin is absolutely contraindicated • 2. Long-acting non-dihydropyridine calcium antagonists † instead of beta blockers as initial therapy B • 3. In patients with documented or suspected CAD and LDL cholesterol 100–129 mg/dl, several therapeutic options are available: B  •    a. Lifestyle and/or drug therapies to lower LDL to <70 mg/dl   •    b. Weight reduction and increased physical activity in persons with the metabolic syndrome   •    c. Institution of treatment of other lipid or non-lipid risk factors; consider use of nicotinic acid or fibric acid for elevated triglycerides or low HDL cholesterol  •  4. ACE inhibitor in patients with CAD or other vascular disease

  18. Beta-Blockers Decrease myocardial oxygen consumption Blunt exercise response Beta-one drugs have theoretical advantage Try to avoid drugs with intrinsic sympathomimetic activity First line therapy in all patients with angina if possible

  19. Cardiac effects of β-adrenergic blocking drugs at the levels of the SA node, AV node, conduction system, and myocardium

  20. Beta BlockersSide Effects Bronchospasm Diminished exercise capacity Negative inotropy Sexual dysfunction Bradyarrhythmia Masking of hypoglycemia Increased claudication Hair loss

  21. Beta BlockersCommon Available Agents Propranolol Atenolol Metoprolol Carvediloll

  22. BB for clinical use

  23. Calcium Channel BlockersMechanisms of Action Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Improved subendocardial perfusion Slowing of heart rate with diltiazem, verapamil

  24. Calcium Channel BlockersMechanisms of Action

  25. Calcium Channel BlockersMechanisms of Action

  26. Mechanisms of anti-ischemic effects of calcium channel blockers

  27. Calcium Channel BlockersSide Effects Palpitations Headache Ankle edema Gingival hyperplasia

  28. Calcium Channel BlockersAvailable Agents Verapamil Diltiazem Nifedipine Nicardipine Amlodipine Felodipine Nisoldipine Bepridil

  29. Contraindications to verapamil or diltiazem

  30. Contraindications to dihydropyridines

  31. Properties of CCB in clinical use

  32. NitratesMechanisms of Action Nitric oxide has been identified as endothelium-derived relaxing factor Organic nitrates are therapeutic precursors of endothelium-derived relaxing factor

  33. NitratesMechanisms of Action Venous vasodilation/pre-load reduction Arterial dilation/after-load reduction Coronary arterial vasodilation Prevention of coronary vasoconstriction Enhancement of coronary collateral flow Antiplatelet and antithrombotic effects

  34. Schematic diagram of effects of nitrate on the circulation

  35. Nitrates in Angina

  36. NitratesReducing Tolerance Smaller doses Less frequent dosing Avoidance of long-acting formulations unless a prolonged nitrate-free interval is provided Build-in a nitrate-free interval o 8-12 hours

  37. NitratesSide Effects Headache Flushing Palpitations Tolerance

  38. NitratesCommon Available Agents Isorbide dinitrate Isorbide mononitrate Long-acting transdermal patches Nitroglycerin sl

  39. Dual role of ACE inhibitors, both preventing and treating cardiovascular disease

  40. ACC/AHA Guidelines for Treatment of Risk Factors (class I) 1. Treatment of hypertension according to Joint National Conference VI guidelines A  2. Smoking cessation therapy B  3. Management of diabetes C  4. Comprehensive cardiac rehabilitation program (including exercise) B  5. LDL-lowering therapy in patients with documented or suspected CAD and LDL cholesterol ≥100 mg/dl, with a target LDL of <70mg/dl A  6. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus C

  41. Specific Goals for Risk Reduction Strategies in Patients with Chronic Stable Angina Smoking Complete cessation Blood pressure <140/90 or 130/85 mm Hg if heart failure or renal insufficiency; <130/85 mm Hg if diabetes Lipid management Primary goal: LDL <70mg/dl Secondary goal: If triglycerides ≥200 mg/dl, then non-HDL should be <130 mg/dl Physical activity Minimum goal: 30 min 3 or 4 d/w Optimal goal: daily Weight management BMI 18.5–24.9 kg/m2 Diabetes management HbA1c <7%

  42. Stable AnginaTreatment Options CABG