Angina pectoris presentation

King Faisal University College of Clinical Pharmacy

Angina Pectoris

By Taher Haddad

No interruption Speaking during the presentation (NOT ALLOWED) Note down your comments & questions There will be time for comments & questions

Before Getting Started

Think & act scientifically

1- Case History with Treatment

2- Definition (what is angina?)

3- Types of Angina

4- Pathophysiology

5- Clinical Presentation

6- Diagnosis (with Tests and Procedures)

7- Goals of Treatment

8- Drug Therapy and Other Measures

Outlines

Case History

• An 80 years old saudi female, non-smoker, D.M. HTN, dyslipidemic, with no previous chest pain, presented with severe shortness of breath & chest tightness. Condition started about 1 month ago, gradually: cough & expectoration of whitish sputum (no hemoptysis).

• One day before admission she's severly dyspnic & distressed.

• Drug history only NSAIDs.• On ICCU admission: fully conscious & oriented.

From a patient file in king Saud Medical Complex, Riyadh

• Result indicated that she had angina, and according to that result, she started receiving the following regimen:

• Carvidelol 12.5 BID• Capoten 12.5 BID• ASA 81 mg OD• Atorva 500 mg BID • Omeprazole 20 mg OD• Iron 200 mg BID• Multivitamin OD• Syp lactoluse 15 ml PO

Treatment for The Case

From a patient file in king Saud Medical Complex, Riyadh

Definition

• Angina is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand.

• It is a common presenting symptom (typically, chest pain) among patients with coronary artery disease.

• Type of chest pain: pressure or discomfort

Medscape.com, Jamshid Alaeddini & Jamshid Shirani

ADAM.COM

Types of Angina

• Angina is classified broadly as stable or unstable, depending on its pattern of occurrence and severity.

medmovie.com

• Stable angina occurs when increased physical activity (e.g., hurrying across a street or climbing a long stairs) which creates a greater demand for oxygen-rich blood to reach heart tissue.

• Unstable angina occurs with lesser degrees of exertion or while at rest. Unstable angina that occurs at rest is the most serious form. This type usually is caused by the formation of a blood clot at the site of a ruptured plaque

in a coronary artery.

Types of Angina (cont.)

Healthcommunities.com (cardiologychannel) 2009

Pathophysiology

• Myocardial ischemia develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand.

• This causes myocardial cells to switch from aerobic to anaerobic metabolism, with a progressive impairment of metabolic, mechanical, and electrical functions.

• Studies have shown that adenosine may be the main chemical mediator of anginal pain. During ischemia, ATP is degraded to adenosine, which, after diffusion to the extracellular space, causes arteriolar dilation and anginal pain.

Medscape.com, Jamshid Alaeddini & Jamshid Shirani

Clinical Presentation

• Angina is a symptom of ischemic heart disease (IHD). Episodes of stable angina typically are brought on by exertion or emotion and are relieved with rest. An attack of stable angina lasts from 1 to 5 minutes and is described as - squeezing,

- choking, - smothering, or - crushing pressure in the chest. • Angina pain may radiate to the shoulders, arms, back,

neck, or jaw.• Patients with atherosclerosis also may experience

sweating, clamminess, shortness of breath (dyspnea).Healthcommunities.com (cardiologychannel) 2009

Clinical Presentation (cont.)

© Reed Group

Medical Disability Advisor, mdguidelines.com

New York Heart Associates, nyheart.net

• Unstable angina causes symptoms that are more severe, more frequent, and occur with modestly increased physical activity and at rest.

• Blood clots may form at anytime and may partially dissolve spontaneously. Whenever this occurs, blood flow to heart tissue is blocked and angina occurs.

• An attack of unstable angina may last several minutes to half an hour or longer.

• Unstable angina is an acute coronary syndrome, which is a medical emergency that requires immediate attention.

Clinical Presentation (cont.)


Diagnosis

• A diagnosis of stable angina is based primarily on symptoms, such as chest pain.

• A diagnosis of unstable angina is made when there is - new onset angina that is severe and/or frequent; - chronic stable angina who develop more frequent,

severe, prolonged, or more easily triggered episodes; - angina at rest.


Diagnostic Tests and Procedures

1- ECG (Electrocardiogram)

It detects and records the electrical activity of the heart. Certain electrical patterns that the ECG detects can suggest whether CAD is likely. However, some people with angina have a normal ECG.

• The ECG is usually normal between attacks. During an attack there may be a transient ST segment depression.

• If the angina is provoked by exertion, an exercise

stress ECG should be performed.

National heart, lung and blood institute

General practice notebook (a U K medical reference on the world wide web)


Butterworth Publishers

2- Stress ECG Testing

Typically, this test involves taking an electrocardiogram (ECG) before, during, and after exercise on a treadmill or stationary bicycle. Patients who are at risk for a coronary event with exercise are, instead, given a drug

to increase the heart rate.




3- Coronary angiogram Is obtained by injecting contrast material into the

bloodstream and taking x-rays of the coronary arteries. This enables the physician to see blockages, malformations, and stenosis in the vessels.

4- Blood Tests Blood tests check the levels of certain fats, cholesterol,

sugar, and proteins in blood. Abnormal levels may indicate risk factors for CAD. Some studies suggest that high levels of CRP (C-reactive protein) in the blood may increase the risk for CAD and heart attack.




Goals of Treatment

• All treatments for people with coronary artery disease have the same goals:

- to decrease the effects of the disease on the quality of life and alleviate symptoms. - to reduce mortality due to CAD progression.

Patient information — Angina treatment , UpToDate.com (Patient Preview)

Drug Therapy

• Currently, there are three main types of drugs used: 1) Nitrates 2) Beta blockers 3) Calcium channel blockers

• Nitrates or beta blockers are usually preferred for initial treatment of angina, and calcium channel blockers may be added if needed.


Drug Therapy (cont.)

• 1) Nitrates

Nitrates improve blood flow by relaxing and dilating veins and arteries, including the coronary arteries.

• Examples: nitroglycerin and isosorbide dinitrate.• Side effects:

The most common side effects of nitrates are headache, lightheadedness, flushing, and an increase in heart rate.



• 2) Beta blockers Beta blockers reduce the heart rate, blood pressure, and

the force of contractions, thereby decreasing the amount of oxygen the heart requires to pump blood.

• Examples: atenolol, metoprolol, nadolol and propranolol.• Side effects: Cardiac effects -- worsen heart failure, bradycardia

Noncardiac effects -- constriction of airways, circulatory problems, Impotence, hallucinations, insomnia, and fatigue


• 3) Calcium channel blockers Calcium channel blockers dilate arteries and lower blood

pressure, which decreases the force of contractions. They also dilate veins, reducing the amount of blood returning to the heart, which reduces the workload of the heart.

• Examples: amlodipine, nifedipine, nicardipine, verapamil and diltiazem.

• Side effects: flushing, dizziness and lightheadedness, headache,

peripheral edema and depression of cardiac function (with non-dihydropyridines)



Other Measures in Managing CAD

• Anticoagulants• Aspirin: (it helps to prevent blood clotting, keeping the

narrowed arteries open and lowering the risk of a heart attack).

• Treat high blood pressure • Treat high cholesterol • Quit smoking • Lose excess weight • Reduce stress • Exercise regularly


Other Treatment Options

• Percutaneous Coronary Intervention (previously called Angioplasty or Balloon Angioplasty)

• CABG (Coronary Artery Bypass Graft Surgery)

2009 American Heart Association website

References

• Patients files from King Saud Medical Complex.• Medscape.com, Jamshid Alaeddini & Jamshid Shirani• ADAM.COM • medmovie.com• Healthcommunities.com (cardiologychannel) 2009• National heart, lung and blood institute • General practice notebook (a U K medical reference on the world wide web)• Butterworth Publishers• Patient information — Angina treatment , UpToDate.com (Patient Preview)• Medical Disability Advisor, mdguidelines.com• New York Heart Associates, nyheart.net • American Heart Association website

Hospital TrainingKing Saud Medical Complex (Riyadh)

Problems from my view

• The program there is unfit able with our training period (6 weeks) , it needs at least 4 months!!

• The program also not matching our training goals & plan, it was all clinical & I think in this training we should be in the pharmacy learning the basic concepts of WHAT WE CALL IT PHARMACIST..

• It was higher than our knowledge & skills• No one from the college told us about the situation there

& we were surprised when Dr. Y. Alo’mi said: every student will go into two department only! (3 weeks for the 1st & 3 for the other one)

Comments & Questions

Angina pectoris presentation

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