Angina pectoris presentation

2. King Faisal University
College of Clinical Pharmacy

3. Angina Pectoris
By
Taher Haddad

4.  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

5. 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

6. 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

7. •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

8. 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

9. ADAM.COM

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

11. •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

12. 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

13. 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

14. Clinical Presentation (cont.)
© Reed Group
Medical Disability Advisor, mdguidelines.com
New York Heart Associates, nyheart.net

15. •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.)
Healthcommunities.com )cardiologychannel( 2009

16. 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.
Healthcommunities.com )cardiologychannel( 2009

17. 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

18. Diagnostic Tests and Procedures
Butterworth Publishers

19. 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.
Diagnostic Tests and Procedures
Healthcommunities.com )cardiologychannel( 2009
National heart, lung and blood institute

20. 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.
Healthcommunities.com )cardiologychannel( 2009
National heart, lung and blood institute
Diagnostic Tests and Procedures

21. 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(

22. 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.
Patient information — Angina treatment , UpToDate.com )Patient Preview(

23. 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.
Patient information — Angina treatment , UpToDate.com )Patient Preview(

24. Drug Therapy (cont.)
•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
Patient information — Angina treatment , UpToDate.com )Patient Preview(

25. •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)
Drug Therapy (cont.)
Patient information — Angina treatment , UpToDate.com )Patient Preview(

26. 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
Patient information — Angina treatment , UpToDate.com )Patient Preview(

27. Other Treatment Options
•Percutaneous Coronary Intervention (previously called
Angioplasty or Balloon Angioplasty)
•CABG (Coronary Artery Bypass Graft Surgery)
2009 American Heart Association website

28. 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

30. Hospital Training
King Saud Medical Complex (Riyadh)

31. 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
1
st
& 3 for the other one)

32. Comments & Questions