CHRONIC STABLE ANGINA ST. LUKE S MEDICAL CENTER - THE HEART INSTITUTE

Transcription

1 CHRONIC STABLE ANGINA ST. LUKE S MEDICAL CENTER - THE HEART INSTITUTE

2 The Heart Institute St. Luke's Medical Center The Heart Institute Office, Ground Floor, St. Luke's Medical Center, 279 E. Rodriguez Sr. Avenue, Quezon City Tel. No.: loc 5402 Organizational Staff 1997 Director Emeritus Director Assistant Director Secretary Treasurer Administrative Division Chairman Cardiovascular Medicine Division Diagnostic/Instrumentation Division Homobono B. Calleja, M.D. Wiliam T. Chua, M.D. Romeo D. Saavedra, M.D. Victoria Tauro-Shia, M.D. Cecilia D. Payot, M.D. Romeo D. Saavedra, M.D. Chairman Antonio S. Sibulo, Jr., M.D. Chairman Isabelo V. Ongtengco, M.D. Chairman

3 chronic stable angina Gregorio G. Rogelio, M.D. Osler Galen F. Cariño, M.D.

4 CPM 1 ST EDITION Algorithm for the Management of Patients with Chronic Stable Angina CHRONIC STABLE ANGINA 1 Chronic stable angina (A) 2 stratify risk (B) high risk? Y amenable to invasive procedures? Y surgical candidate Figure IA N 6 N medical management (C) Figure 1 409

5 CHRONIC STABLE ANGINA Algorithm for the Management of Chronic Stable Angina in Patients Amenable to Invasive Procedures CPM 1 ST EDITION Figure I surgical candidate coronary angiography suitable for PTCA?* PTCA* 5 6 suitable for CABG?** CABG** 6 medical management Figure 1A * PTCA - percutaneous transluminal coronary angioplasty ** CABG - coronary artery by pass graft 410

6 CPM 1 ST EDITION Footnotes A. Stable angina is defined as having the following clinical features: predictable pattern of chest discomfort, begins gradually lasting over a period of minutes, precipitated by effort & relieved by rest or nitrates [1]. B. Risk stratification should be based on the following parameters: clinical findings, LV function & low level treadmill exercise test, stress thallium, dipyridamole stress test, or dobutamine stress echocardiogram [2]. These clinical predictors of important prognostic significance include: 1. poor exercise capacity (<5 METS) 2. >2 min ischemic ST segment depression at low workload (< stage 2 or <130 beats/min without medications) 3. early onset (stage l) or prolonged duration (>5 min) of ST segment depression 4. multiple leads (>5) with ST segment depression 5. ST segment elevation 6. abnormally low peak systolic BP (<130 mmhg) or a fall of >10 mmhg systolic BP during exercise 7. inability to attain the target heart rate (without medications) 8. exercise-induced angina 9. ventricular couplets or ventricular tachycardia at a low workload 10. multiple severe initial thallium defects 11. multiple areas showing thallium redistribution [3] 12. increased lung/heart thallium ratio [4] 13. transient ischemic left ventricular dilation on stress thallium [5] 14. left ventricular dysfunction on echo [6] C. Medical Treatment 1. Nitrates decrease myocardial oxygen demand by reducing both preload & afterload, & enhance myocardial blood flow by prevention of coronary vasoconstriction, reduction of LVEDP & dilation of coronary arteries [7]. 2. Beta-blockers decrease heart rate & systolic BP, increase diastolic rilling period & coronary perfusion time, decrease myocardial oxygen demand. Beta-blockers alone or in combination with Ca antagonists are associated with MI prevention & reduction of anginal attacks, & increased anginal threshold [8]. 3. Ca channel blockers reduce afterload & cause coronary vasodilation & prevent coronary spasm [9]. 4. Aspirin (platelet inhibitors) mg reduces cardiac events by 34-87% [10-11]. CHRONIC STABLE ANGINA Medical management includes control of modifiable risk factors such as smoking, hypertension, diabetes & hypercholesterolemia, & aggravating factors such as fever, anemia, thyrotoxicosis, infection, etc. D. Coronary Angiography [12-15] 1. With significant (60%) left main coronary artery disease & for most with significant (70%) 3-vessel coronary artery disease, CABG is advised. 2. With significant 2 vessel disease & 1-vessel disease, the option of CABG, PTCA or medical treatment will be considered. 3. With critical obstruction of the proximal left anterior descending artery with significant obstruction of one other major vessel & moderate angina &/or inducible ischemia, CABG or PTCA is advised. 4. With significant single-vessel disease, the decision for CABG, PTCA or medical treatment is made individually. PTCA or CABG is favored for those with non-invasive testing which indicates exercise-inducible ischemia (<6 METS), poor functional capacity & a critical obstruction (>70%). References 1. Lambert CR. Fathophysiology of stable angina pectoris. In Crawford M (ed): Cardiology Clinics. Philadelphia, W.B. Saunders Company 1991;9:1-10, 2. Hammermeister KE, Deronen TA, Dodge HY. Variables predictive of survival in patients with coronary disease. Circulation 1977;59: Brown KA, Boucher CA, Okada RD, et al. Prognostic value of exercise thallium 201 imaging in patients presenting for evaluation of chest pain. J Am Coll Cardiol 1984;1; Kaul S, Finkelstein DM, Homma S et al. Superiority of quantitative exercise thallium 201 variables in determining long-term prognosis in ambulatory patients with chest pain; a comparison with cardiac catheterization. J Am Coll Cardiol 1988;12: Weiss AT, Berman DS, Lew AS et al. Transient ischemic dilation of the left ventricle on stress thallium 201 scintigraphy: a marker of severe & extensive coronary artery disease. J Am Coll Cardiol 1987;9: Mock MB, Ringquist I, Fisher LD. Survival of medically treated patients in the coronary artery surgery study registry. Circulation 1982;66: Udho T. Medical therapy of stable angina pectoris. In Crawford M (ed):cardiology Clinics. Philadelphia, W.B. Saunders Company 1991; Rutherford MB, Braunwald E. Chronic ischemic heart disease. In Braunwald E (ed): Heart disease: A textbook of cardiovascular medicine 14th ed. Philadelphia, W.B. Saunders Company 1991; , 9. Packer M. Drug therapy: combined beta adrenergic & calcium entry blockade in angina pectoris. N Engi J Med 1989;320; Eduardson N, Jahnmatz B et al. Double blind trial of Aspirin in primary prevention of myocardial infarction in patients with stable angina pectoris. Lancet 1992;340: Ridker PM, Manson JEE, Gaziano M, et al. Low dose 411

7 CHRONIC STABLE ANGINA aspirin therapy for chronic stable angina: A randomized, placebo-controlled trial. Ann Intern Med 1991;114: Vamaukas E & the European Coronary Surgery Study Group. Twelve year follow-up of survival in the randomized European Coronary surgery study. N Engi J Med 1988; Alderman EL, Boyrassa MG, Cohen LS, et al. Ten-year follow-up of survival & myocardial infarction in the randomized coronary artery surgery study. Circulation 1990;82: Ellis S, Fischer L et al. Comparison of coronary angioplasty with medical treatment for single & double vessel coronary artery disease with left anterior descending coronary involvement: Longterm outcome based on an Emory- CASS registry study. AM heart J 1989;118: The VA & the Coronary Artery Bypasss Surgery Cooperative Study Group. Eighteen-year follow-up in the veterans affairs cooperative study of coronary artery bypass surgery for stable angina. Circulation 1992;89: CPM 1 ST EDITION 412

8 CHRONIC STABLE ANGINA Drugs Mentioned in the Treatment Guideline CPM 1 ST EDITION The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's reference, available drugs are listed under each therapeutic class. Aspirin Aspilets Astrix Bayer Aspirin COR Beta blockers Atenolol Serten Tenormin UL Atenolol Betaxolol Kerlone Bisoprolol Concore Carteolol Mikelan Metoprolol Betaloc Betazok Cardiosel USA Metoprolol Nadolol Corgard Pindolol Visken Propranolol Bedranol Duranol Inderal Propranolol- Phoenix Propranolol- Scanpharm UL Propranolol Sotalol Sotalex Atenolol/Chlorthalidone Tenoretic Metoprolol/Hydrochlorothiazide Betazide Pindolol/Clopamide Viskaldix Calcium Channel Blockers Amlodipine Norvasc Diltiazem Dilatam Diltelan Dilzem/Dilzem SA/SR Servazen Tildiem Zilden Felodipine Munobal Plendil ER Isradipine Dynacirc Icaz SRO Lacidipine Lacipil Manidipine Caldine Minadil Nicardipine Cardepine Selevax Nifedipine Adalat Calcibloc Cardionorm Darat Fedcor Nifelan Nimodipine Nimotop Nitrendipine Baypress Verapamil Hinorm Isoptin/Isoptin SR Verelan Atenolol/Nifedipine Niften Organic Nitrates & Nitrites Isosorbide Cedocard Elantan Elantan Long Imdur Durules Ismo Isoket Isoket IV Isoket Spray Iso-Mack Retard Iso-Mack Spray Isordil Isordil Tembids Monovas Nitorol Nitroglycerin Deponit 5/Deponit Minitran TDP Nitradisc Nitrol Nitrostat Perlinganit Transderm-Nitro Pentaerythritol tetranitrate Peritrate...148