Management of Chronic CAD: stable angina
Non- pharmacological
- Address modifiable risk factors (lipid lowering, cigarette cessation)
- Strict diabetic control
- Optimum blood pressure control
- Correct illnesses that can precipitate or exacerbate angina (anaemia, infection, thyroid disease)
- Encouraged Regular exercise
Important Point
- Blood Pressure : < 140/90 mmHg (Diabetes: BP 130/80 mmHg)
- Serum cholesterol < 4.0 mmol/L
- HDL > than 1 mmol/L
- LDL < than 2 mmol/L
Pharmacological therapy
A- Vasodilator – GTN - Venodilatorsx
(Glyceryl Trinitrate 0.3-1mg sublingual). Isosorbide mononitrate – 10-60mg orally bd
Action
- Venodilation: ↓ cardiac preload, decreasing wall stress and O2 demand
- Relieving angina and improving exercise tolerance
- does not affect mortality.
Contraindicated:
sildenafil (Viagra), RT ventricular Infarction = and severe hypotension; they result in vasodilation
Nitrates are contraindicated in case of hypotension, myocardial infarction of the right ventricle, and recent use of PDE-5 inhibitors like Sildenafil, because in these situations nitrates can cause really severe hypotension.
B- Beta Blocker : 1st line
- Atenolol (Tenormin) 25-100mg daily
- Bisoprolol (Concor) 2.5-10mg/day
Action
- ↓ heart rate
- ↓ BP
- ↓ myocardial O2 demand (!! heart failure)
- β-blockers reduce both morbidity and mortality. (Post-MI & HF)
C/I: Prinzmetal angina, bradycardia, cardiogenic shock, and cocaine-related ACS.
Calcium channel blockers (CCBs)
- Second-line therapy
- Improve myocardial oxygen supply by ↓ coronary vascular resistance, myocardial demand is ↓ by a ↓ in myocardial contractility.
- Verapamil and Diltiazem Inhibit cardiac conductive tissue.
- Contraindicated: Bradycardia, H block, LVF
- Do not use short-acting dihydropyridines, which increase mortality rates in patients with ACS of CCBs; verapamil; diltiazem use dipines
- Long-acting agents are safe and effective in chronic stable angina
Do not combine β- blockers with non-dihydropyridine calcium antagonists).
If these fail to control symptoms or are not tolerated, trial other agents.* Ranolazine: SDLZ will use
Primary and Secondary Prevention
- Primary Prevention
- prevention of atherosclerotic disease process. (Atorvastatin 20 mg CL)
- Aspirin: Not recommend in primary prevention !!!Z
- Secondary Prevention
- treatment of atherosclerosis (its complication) . Atorvastatin 80 mg
Read SDL: QRISK®3 risk assessment tool https://qrisk.org/ - Age, Sex, Ethnicity, Smoking/DM Status - CKD, Angina H attack in 1st degree relative, RA, Migraines, HTN, SLE, Antipsychotics, Steroid tablets, viagra, steroids. CL/HDL ration, Systolic BP - Standard deviation of recent systolic BP reading - Height/Weight
Secondary Prevention of IHD
Medications that decrease morbidity and mortality
-
Aspirin 75mg daily – All patient unless contraindications. S/E GI bleeding
-
ACE inhibitors – used if hypertension, heart failure.
-
Statins (Lipitor ): elderly ≥ 75 y. & left ventricular (LV) dysfunction (ejection fraction [EF] <40%)
Atorvastatin 20 mg is recommended for the primary prevention of cardiovascular disease in people with a 10-year risk of cardiovascular disease of 10% or higher. In patients with established cardiovascular disease, NICE recommends atorvastatin 80 mg, unless there are potential drug interactions, a high risk of adverse effects or a different patient preference.
Algorithm for Management of Patient’s with Stable Angina
SDL revise Kumar 1083CC
FIRST MEDICAL THEN ADD BB THEN PCI