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Christopher P Cannon,
MD
Deputy Editor
Gordon M Saperia,
MD, FACC
Last literature review version 17.3: September 2009 | This topic last
updated: August 12, 2009 (More)
INTRODUCTION Angina pectoris occurs whenever myocardial oxygen
demand exceeds oxygen supply; the clinical manifestation is chest discomfort
caused by transient myocardial ischemia. A clinical diagnosis of angina has a
90 percent predictive accuracy for the presence of coronary heart disease
(CHD). The management of stable angina involves pharmacologic intervention
to prevent or minimize ischemia, reduction of risk factors for CHD and
revascularization in some patients.
Our recommendations for the management of stable angina are generally in
accord with those made in the 2002 American College of Cardiology/American
Heart Association (ACC/AHA) guidelines for the management of patients with
chronic stable angina and the limited revisions in the 2007 ACC/AHA chronic
angina focused update [ 1,2] .
The initial diagnosis of angina, patients with angina that is refractory to
conventional therapeutic approaches, and unstable angina are discussed
separately. ( See "Diagnostic approach to chest pain in adults" and see "New
therapies for angina pectoris" and see "Overview of the management of
unstable angina and acute non-ST elevation myocardial infarction" ).
DEFINITIONS There are two types of angina:
Stable angina, which refers to chest discomfort that occurs predictably
and reproducibly at a certain level of exertion and is relieved with rest
or nitroglycerin .
Unstable angina, which is an acute coronary syndrome that
encompasses a variety of clinical conditions including the new onset of
ACE inhibitors are recommended for patients with stable angina who
are not lower risk as defined as those with normal LVEF in whom
cardiovascular risk factors are well controlled and revascularization has
been performed
ACE inhibitors may be considered for lower risk patients with mildly
reduced or normal LVEF in whom risk factors are well controlled and
revascularization has been performed
Angiotensin receptor blockers (ARBs) are recommended for patients
who have hypertension, have indications for but are intolerant of ACE
inhibitors, have heart failure, or have had and MI with LVEF 40 percent
ARBs may be considered in combination with ACE inhibitors for heart
failure due to left ventricular systolic dysfunction
Aldosterone antagonists ( spironolactone or eplerenone ) are
recommend for post MI patients without significant renal dysfunction or
hyperkalemia who are already receiving therapeutic doses of an ACE
inhibitor and a beta blocker, have an LVEF 40 percent and have either
diabetes or heart failure (strong recommendation)
New therapies A number of new medical and invasive therapies have been
evaluated for use in patients with stable angina. Only
ranolazine , a fatty acid
oxidation inhibitor, has been approved for clinical use and its role is evolving
[14] . The absence of a proarrhythmic effect of ranolazine in the MERLIN-TIMI
36 trial has mitigated concerns of possible QT interval prolongation. We
believe ranolazine can be used as an option for angina patients who have
failed all other antianginal therapies. ( See "Clinical features and treatment of
ventricular arrhythmias during acute myocardial infarction" , section on
Ranolazine).
Other potential therapies include ivabradine and fasudil, and mechanical
therapies such as enhanced external balloon counterpulsation, spinal cord
stimulation, and transmyocardial laser revascularization. These approaches
are discussed separately. ( See "New therapies for angina pectoris" ).
Exacerbating factors Treatment of any underlying medical conditions that
might aggravate myocardial ischemia, such as hypertension, fever,
tachyarrhythmias (eg, atrial fibrillation), thyrotoxicosis, anemia or
polycythemia, hypoxemia, or valvular heart disease should be undertaken.
Asymptomatic low grade arrhythmias are not treated routinely, but may
require therapy under circumstances, such as left ventricular dysfunction.
There should also be modification of activities that exacerbate angina, such as
exercise in cold weather or after a meal.
Summary Since beta blockers and calcium channel blockers appear to be of
risk included emergency surgery, left main disease, and left ventricular
dysfunction.
Actuarial survival at 5 and 10 years was 75 and 49 percent, respectively, and
cardiac-event free survival was 60 and 27 percent, respectively. Mortality was
associated with comorbidities such as diabetes mellitus, left ventricular
dysfunction, peripheral vascular disease, and postoperative stroke.
Summary While older adults have been underrepresented in clinical trials,
there are sufficient data that medical and revascularization therapies are
effective in older adults. The decision whether to continue with optimal
medical therapy or perform revascularization requires the elderly patient's
understanding of the strengths and weaknesses of each approach and a
respect by the health care delivery team of that patient's subsequent
preferences.
FOLLOW-UP Patients with chronic stable angina that is effectively
managed require follow-up on a regular basis, eg, every four to six months
during the first year, and every 4 to 12 months thereafter [ 1] . At each visit, a
detailed history should be obtained and physical examination performed. In
particular, it is important to establish:
A change in physical activity
Any change in the frequency, severity, or pattern of angina
Tolerance of and compliance with the medical program
Modification of risk factors
The development of new or worsened comorbid illnesses
Routine laboratory examination includes glucose, lipid profile, and hematocrit.
An assessment of electrolytes and renal and thyroid function is guided by
symptoms or history. An ECG should be obtained if medications are altered or
if the history or physical examination have changed.
The ACC/AHA Task Force has published recommendations for noninvasive
testing and angiography during follow-up [ 1] . These studies are primarily
indicated when there is a change in clinical status, such as a change in anginal
frequency, severity, or pattern; a new MI; new or worsening heart failure; or
the appearance of a new murmur suggesting significant valvular disease.
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REFERENCES
1. Gibbons, RJ, Abrams, J, Chatterjee, K, et al. ACC/AHA 2002 guideline
update for the management of patients with chronic stable angina.
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38. Thompson, RC, Holmes, DR, Gersh, BJ, et al. Predicting early and
intermediate-term outcome of coronary angioplasty in the elderly.
Circulation 1993; 88:1579.
39. Batchelor, WB, Anstrom, KJ, Muhlbaier, LH, et al. Contemporary outcome
trends in the elderly undergoing percutaneous coronary interventions:
results in 7,472 octogenarians. National Cardiovascular Network
Collaboration. J Am Coll Cardiol 2000; 36:723.
40. Thompson, RC, Holmes, DR, Grill, DE, et al. Changing outcome of
angioplasty in the elderly. J Am Coll Cardiol 1996; 27:8.
41. Sadeghi, HM, Grines, CL, Chandra, HR, et al. Percutaneous coronary
interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors'
safety profile. J Am Coll Cardiol 2003; 42:428.
42. Williams, DB, Carrillo, RG, Traad, EA, et al. Determinants of operative
mortality in octogenarians undergoing coronary bypass. Ann Thorac
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43. Kolh, P, Kerzmann, A, Lahaye, L, et al. Cardiac surgery in octogenarians.
Peri-operative outcome and long-term results. Eur Heart J 2001;
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44. Rosengart, TK, Finnin, EB, Kim, DY, et al. Open heart surgery in the
elderly: results from a consecutive series of 100 patients aged 85 years
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45. Conaway, DG, House, J, Bandt, K, et al. The elderly: health status
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46. Peterson, ED, Cowper, PA, Jollis, JG, et al. Outcomes of coronary artery
bypass graft surgery in 24,461 patients aged 80 years or older.
Circulation 1995; 92:II85.
47. He, GW, Achuff, TE, Ryan, WH, et al. Determinants of operative mortality
in elderly patients undergoing coronary artery bypass grafting.
Emphasis on the influence of internal mammary artery grafting on
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48. Galbut, DL, Traad, EA, Dorman, MJ, et al. Coronary bypass grafting in
the elderly> Single versus bilateral internal mammary artery grafts. J
Thorac Cardiovasc Surg 1993; 106:128.
49. Canver, CC, Nichols, RD, Cooler, SD, et al. Influence of increasing age on
long-term survival after coronary artery bypass grafting. Ann Thorac
Surg 1996; 62:1123.
50. Heijmeriks, JA, Pourrier,S, Dassen, P, et al. Comparison of quality of life
after coronary and/or valvular cardiac surgery in patients 75 years of
age with younger patients. Am J Cardiol 1999; 83:1129.
51. Yamamuro, M, Lytle, BW, Sapp, SK, et al. Risk factors and outcomes
after coronary reoperation in 739 elderly patients. Ann Thorac Surg
2000; 69:464.
GRAPHICS
Preparation
Onset
of
Route of
action,
administration minutes
Duration
of action
Dose
Sublingual
tablet
2-5
15-30 min
0.15-0.9
mg
Sublingual spray
2-5
15-30 min
0.4 mg
Up to 7
hours
2
percent,
15x15
cm (7.5
to 40
mg)
Ointment
2-5
Nitroglycerin
Transdermal
30
8-14 hours
0.2-0.8
mg/hour
q 12
hours
Oral sustained
release
30
4-8 hours
2.5-13
mg
Intravenous
2-5
During
infusion
tolerance
in 7-8 hrs
5-200
g/min
Sublingual
2-5
Up to 60
min
2.5-15
mg
30
Up to 8
hours
5-80 mg
BID or
TID
Oral
Isosorbide
dinitrate
Spray
2-5
2-3 min
1.25
mg/day
Chewable
2-5
2-2.5 hours
5 mg
30
Up to 8
hours
40 mg
OD or
BID
2-5
During
infusion
tolerance
in 7-8 hrs
1.25-5
mg/hour
Intravenous
Isosorbide
mononitrate,
extended
release
Isosorbide
mononitrate,
extended
release
Pentaerythroid
tetranitrate
Eyrthritol
tetranitrate
Oral
Oral
Sublingual
30
30-60
2-5
12-24
hours
20-40
mg BID
60-240
mg/day
12 hours
30-120
mg once
daily
Not known
10 mg
as
needed
Sublingual
2-5
Not known
5-10 mg
as
needed
Oral
30
Not known
10-30
mg TID
Condition
Recommended
treatment (and
alternative)
Avoid
Medical conditions
Systemic hypertension
Beta-blockers (calcium
antagonists)
Migraine or vascular
headaches
Beta-blockers
(verapamil or diltiazem)
Asthma or chronic
obstructive pulmonary
disease with
bronchospasm
Verapamil or diltiazem
Hyperthyroidism
Beta-blockers
Raynaud's syndrome
Long-acting
slow-release calcium
antagonists
Insulin-dependent
diabetes mellitus
Beta-blockers
(particularly if prior
myocardial infarction) or
long-acting
slow-release calcium
antagonists
Non-insulin-dependent
diabetes mellitus
Beta blockers or
long-acting
slow-release calcium
antagonists
Depression
Long-acting
slow-release calcium
antagonists
Beta-blockers or calcium
antagonists
Beta-blockers
Beta-blockers
Beta-blockers
Severe peripheral
vascular disease with
rest ischemia
Calcium antagonists
Beta-blockers
Sinus bradycardia
Long-acting
slow-release calcium
antagonist that do not
decrease heart rate
Beta-blockers
Supraventricular
tachycardia
Verapamil, diltiazem, or
beta-blockers
Atrioventricular block
Long-acting
slow-release calcium
antagonists that do not
slow A-V conduction
Verapamil, diltiazem, or
beta-blockers
Ventricular arrhythmias
Beta blockers
Beta-blockers,
diltiazem,
verapamil
Beta-blockers,
diltiazem,
verapamil
40 percent)
Beta-blockers
Amlodipine or felodipine
Verapamil,
<40 percent)
(nitrates)
diltiazem
Mitral regurgitation
Mitral stenosis
Beta-blockers
Long-acting slow-release
dihydropyridines
Long-acting slow-release
dihydropyridines
Beta-blockers
Hypertrophic
cardiomyopathy
Beta-blockers,
non-dihydropyridine
calcium antagonist
Nitrates,
dihydropyridine
calcium
antagonists
Class
New York
Heart
Association
functional
classification
Canadian
Cardiovascular
Society functional
classification
Specific
activity scale
Patients with
cardiac disease
but without
resulting
limitations of
physical activity.
Ordinary physical
activity does not
cause undue
fatigue,
palpitation,
dyspnea, or
anginal pain.
Ordinary physical
activity, such as
walking and climbing
stairs, does not cause
angina. Angina with
strenuous or rapid
prolonged exertion at
work or recreation.
Patients can
perform to
completion any
activity
requiring 7
metabolic
equivalents, eg,
can carry 24 lb
up eight steps;
do outdoor
work (shovel
snow, spade
soil); do
recreational
activities
(skiing,
basketball,
squash,
handball,
jog/walk 5
mph).
II
Patients with
cardiac disease
resulting in slight
limitation of
physical activity.
They are
comfortable at
rest. Ordinary
physical activity
results in fatigue,
palpitation,
dyspnea, or
anginal pain.
Slight limitation of
ordinary activity.
Walking or climbing
stairs rapidly, walking
uphill, walking or stair
climbing after meals, in
cold, in wind, or when
under emotional
stress, or only during
the few hours after
awakening. Walking
more than two blocks
on the level and
climbing more than
one flight of ordinary
stairs at a normal pace
and in normal
conditions.
Patients can
perform to
completion any
activity
requiring
5
metabolic
equivalents, eg,
have sexual
intercourse
without
stopping,
garden, rake,
weed, roller
skate, dance
fox trot, walk at
4 mph on level
ground, but
cannot and do
not perform to
completion
activities
requiring
7
metabolic
equivalents.
III
Patients with
cardiac disease
resulting in
marked limitation
of physical activity.
They are
comfortable at
rest. Less than
ordinary physical
activity causes
fatigue,
palpitation,
dyspnea, or
anginal pain.
IV
Patient with
cardiac disease
resulting in
inability to carry on
any physical
activity without
discomfort.
Symptoms of
cardiac
insufficiency or of
the anginal
syndrome may be
present even at
rest. If any
physical activity is
undertaken,
discomfort is
increased.
Marked limitation of
ordinary physical
activity. Walking one
to two blocks on the
level and climbing
more than one flight in
normal conditions.
Patients can
perform to
completion any
activity
requiring
2
metabolic
equivalents, eg,
shower without
stopping, strip
and make bed,
clean windows,
walk 2.5 mph,
bowl, play golf,
dress without
stopping, but
cannot and do
not perform to
completion any
activities
requiring > 5
metabolic
equivalents.
Inability to carry on
any physical activity
without discomfort anginal syndrome may
be present at rest.
Patients cannot
or do not
perform to
completion
activities
requiring > 2
metabolic
equivalents.
Cannot carry
out activities
listed above
(Specific activity
scale III).
-11)
5)
* Although the published data are limited, patients with these findings
will probably not be at low risk in the presence of either a high-risk
treadmill score or severe resting left ventricular dysfunction (LVEF < 35
percent).
Reproduced with permission from: ACC/AHA/ACP Guidelines for the
Management of Patients with Chronic Stable Angina. J Am Coll Cardiol
1999; 33:2092. Copyright 1999 American College of Cardiology.
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