CHRONIC STABLE ANGINA

ST. LUKES MEDICAL CENTER - THE HEART INSTITUTE

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.: 723-0101 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

chronic stable angina

Gregorio G. Rogelio, M.D. Osler Galen F. Cario, M.D.

CPM 1ST EDITION

CHRONIC STABLE ANGINA

Algorithm for the Management of Patients with Chronic Stable Angina

1 Chronic stable angina (A) 2 stratify risk (B) 3 Y 4 amenable to invasive procedures? 6 N medical management (C) Y 5 surgical candidate

high risk?

Figure IA

FigUre 1
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Algorithm for the Management of Chronic Stable Angina in Patients Amenable to Invasive Procedures
Figure I 1 surgical candidate 2 coronary angiography 3 suitable for PTCA?* 4

PTCA*

5 suitable for CABG?**

CABG**

6 medical management

FigUre 1A

* PTCA - percutaneous transluminal coronary angioplasty ** CABG - coronary artery by pass graft

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Footnotes A. Stable angina is defined as having the following clinical features: predictable pattern of chest discomfort, begins gradually lasting over a period of 10-15 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]

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;59:421. 3. 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;1994. 4. 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;12:25. 5. 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;9:752. 6. Mock MB, Ringquist I, Fisher LD. Survival of medically treated patients in the coronary artery surgery study registry. Circulation 1982;66:562-68. 7. Udho T. Medical therapy of stable angina pectoris. In Crawford M (ed):Cardiology Clinics. Philadelphia, W.B. Saunders Company 1991;9-73-87. 8. 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;1292-1364, 9. Packer M. Drug therapy: combined beta adrenergic & calcium entry blockade in angina pectoris. N Engi J Med 1989;320;709. 10. 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;340:1421-25. 11. Ridker PM, Manson JEE, Gaziano M, et al. Low dose

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) 75-325 mg reduces cardiac events by 34-87% [10-11].

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aspirin therapy for chronic stable angina: A randomized, placebo-controlled trial. Ann Intern Med 1991;114:83539. 12. Vamaukas E & the European Coronary Surgery Study Group. Twelve year follow-up of survival in the rando mized European Coronary surgery study. N Engi J Med 1988;319-332. 13. 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;82:1629. 14. 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 EmoryCASS registry study. AM heart J 1989;118:208. 15. 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;89:12130.

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Drugs Mentioned in the Treatment Guideline

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................................155 Astrix. ..................................155 Bayer Aspirin.......................155 COR-30................................156 Beta blockers Atenolol Serten. ...................................129 Tenormin..............................130 UL Atenolol. ........................130 Betaxolol Kerlone. ...............................130 Bisoprolol Concore................................130 Carteolol Mikelan................................130 Metoprolol Betaloc.................................130 Betazok................................131 Cardiosel..............................131 USA Metoprolol...................131 Nadolol Corgard. ...............................131 Pindolol Visken. ..................................131 Propranolol Bedranol...............................131 Duranol................................131 Inderal..................................132 Propranolol Phoenix..............................132 Propranolol Scanpharm.........................132 UL Propranolol. ...................132 Sotalol Sotalex. ................................132 Atenolol/Chlorthalidone Tenoretic. .............................132 Metoprolol/Hydrochlorothiazide Betazide. ..............................132 Pindolol/Clopamide Viskaldix..............................132 Calcium Channel Blockers Amlodipine Norvasc................................132 Diltiazem Dilatam. ...............................134 Diltelan. ...............................134 Dilzem/Dilzem SA/SR.........134 414 Servazen...............................134 Tildiem.................................134 Zilden...................................134 Felodipine Munobal...............................134 Plendil ER............................134 Isradipine Dynacirc...............................134 Icaz SRO..............................136 Lacidipine Lacipil..................................136 Manidipine Caldine.................................136 Minadil.................................136 Nicardipine Cardepine.............................136 Selevax.................................136 Nifedipine Adalat...................................136 Calcibloc..............................136 Cardionorm..........................138 Darat. ...................................138 Fedcor..................................138 Nifelan..................................138 Nimodipine Nimotop...............................138 Nitrendipine Baypress...............................138 Verapamil Hinorm.................................138 Isoptin/Isoptin SR................138 Verelan. .................................139 Atenolol/Nifedipine Niften. ...................................139 Organic Nitrates & Nitrites Isosorbide Cedocard..............................144 Elantan. .................................144 Elantan Long........................144 Imdur Durules......................144 Ismo 20. ...............................144 Isoket....................................144 Isoket IV. .............................144 Isoket Spray.........................144 Iso-Mack Retard. .................144 Iso-Mack Spray....................146 Isordil...................................146 Isordil Tembids. ...................146 Monovas. .............................146 Nitorol..................................146 Nitroglycerin Deponit 5/Deponit 10. .........146 Minitran TDP.......................146 Nitradisc...............................146 Nitrol....................................147 Nitrostat. ..............................147 Perlinganit............................147 Transderm-Nitro. .................147 Pentaerythritol tetranitrate Peritrate............................... 148