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{{Chronic stable angina}} | {{Chronic stable angina}} | ||
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan. M.B.B.S.]]; [[User:Rim Halaby|Rim Halaby]] | ||
==Overview== | ==Overview== | ||
The goal of the management of [[Chronic stable angina definition|chronic stable angina]] is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by [[myocardial | The goal of the management of [[Chronic stable angina definition|chronic stable angina]] is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by [[myocardial infarction]]n or development of [[heart failure]]. The mainstays of the treatment of [[chronic stable angina]] are patient education, lifestyle changes and medical therapy.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> In patients with chronic stable angina, immediate symptomatic relief is achieved with [[Chronic stable angina nitrate therapy|short-acting sublingual nitrates]] and long term symptom relief is achieved with [[Chronic stable angina beta blocker therapy|beta blockers]] as first line therapy, or [[Chronic stable angina treatment calcium channel blockers|calcium channel blockers]] and [[Chronic stable angina nitrate therapy|long-acting nitrates]] when beta blockers are contraindicated. Drugs that improve the quality of life and are associated with a better prognosis include: [[Chronic stable angina treatment aspirin|low dose aspirin]], [[Chronic stable angina beta blocker therapy|beta-blockers]] and [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
* Lifestyle modification and medical therapy are the | * Lifestyle modification and medical therapy are the first line treatment of patients with chronic stable angina. | ||
===Goals of the Medical Therapy=== | ====Goals of the Medical Therapy==== | ||
* | * To decrease premature cardiovascular death: | ||
** | ** By decreasing incidence of [[myocardial infarction]] and [[heart failure]] | ||
** | ** By increasing survival | ||
* | * To improve the quality of life: | ||
** | ** By decreasing the severity and frequency of angina | ||
** | ** By increasing exercise tolerance<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
===Management Plan=== | ====Management Plan==== | ||
Shown below is an image illustrating the different components of the management plan of a patient with chronic stable angina: | |||
==Patient Education== | [[Image:Management_of_chronic_stable_angina.png|center|450px|Management plan for chronic stable angina.]] | ||
====Patient Education==== | |||
* Importance of life style changes | * Importance of life style changes | ||
* Importance of compliance to medications | * Importance of compliance to medications<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Risk Factors Modification== | ===Risk Factors Modification=== | ||
====Lipid | ====Lipid Profile==== | ||
* Daily physical activity | * Daily physical activity | ||
* Weight management | * Weight management | ||
* Diet low in saturated fats, trans fat, cholesterol | * Diet low in saturated fats, trans fat, cholesterol | ||
* Pharmacotherapy with [[Chronic stable angina treatment anti-lipid agents|lipid lowering drug therapy]] ideally [[HMG-CoA reductase inhibitor]] | * Pharmacotherapy with [[Chronic stable angina treatment anti-lipid agents|lipid lowering drug therapy]] ideally [[HMG-CoA reductase inhibitor]] to reduce [[LDL|LDL cholesterol]] level below 100 mg/dl (less than 70 mg/dl in [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|high-risk patients]]). | ||
====Treatment of | ====Treatment of Hypertension==== | ||
* Physical activity | * Physical activity | ||
* Moderate alcohol intake if any | * Moderate alcohol intake if any | ||
* Diet low in sodium and rich in fruits, vegetables and low fat dairy products | * Diet low in sodium and rich in fruits, vegetables and low fat dairy products | ||
* Pharmacotherapy with [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]] and/or [[Chronic stable angina beta blocker therapy|beta-blockers]] | * Pharmacotherapy with [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]] and/or [[Chronic stable angina beta blocker therapy|beta-blockers]] | ||
====Control of | ====Control of Diabetes==== | ||
* Glycemic control | * Glycemic control | ||
====Physical | ====Physical Activity==== | ||
* 30 to 60 minutes of moderate aerobic exercise at least five days a week. | * 30 to 60 minutes of moderate aerobic exercise at least five days a week. | ||
====Weight | ====Weight Management==== | ||
* Target BMI: between 18.5 and 24.9 Kg/ | * Target BMI: between 18.5 and 24.9 Kg/m<sup>2</sup> | ||
* Target waist circumference: less than 40 inches in males and less than 35 inches in females. | * Target waist circumference: less than 40 inches in males and less than 35 inches in females | ||
====Smoking Cessation==== | |||
* Strong recommendation to stop smoking<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | |||
====Contraindicated medications==== | |||
{{MedCondContrAbs|MedCond = Angina pectoris|Almotriptan|Sumatriptan}} | |||
==Prevention of Acute Coronary Syndrome== | ==Prevention of Acute Coronary Syndrome== | ||
====Aspirin==== | ====Aspirin==== | ||
* | * [[Chronic stable angina treatment aspirin|Aspirin]] (75-162 mg/day) minimizes the risk of thrombosis superimposed on the chronic fixed obstruction. | ||
* [[Chronic stable angina treatment aspirin|Aspirin]] should be used indefinitely unless contraindicated. | |||
* If [[Chronic stable angina treatment aspirin|Aspirin]] is contraindicated, the second line treatment is [[clopidogrel]]. | |||
====Beta Blockers==== | ====Beta Blockers==== | ||
* | * [[Chronic stable angina treatment beta blockers|Beta blockers]] reduces [[heart rate]] and myocardial oxygen demands, as well as the risk of [[fatal arrhythmias]] as a consequence of [[plaque rupture]]. | ||
* [[Chronic stable angina treatment beta blockers|Beta blockers]] have shown to prevent [[ischemia]] even with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with [[ischemic heart disease]]. | |||
* [[Chronic stable angina treatment beta blockers|Beta blockers]] should be used at least three years following myocardial infaction or acute coronary syndrome. | |||
* If left ventricular dysfunction is present, [[metoprolol]], [[carvedilol]] or [[bisoprolol]] should be used. | |||
====ACE Inhibitors==== | ====ACE Inhibitors==== | ||
*Strong consideration should be given to the initiation of | *Strong consideration should be given to the initiation of [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]] as potential disease modifying therapy. | ||
* [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACE inhibitors]] should be given to almost all patients with chronic stable angina especially in the presence of [[diabetes]], [[hypertension]] or [[chronic kidney disease]]. | |||
* | *[[Chronic stable angina treatment calcium channel blockers|Calcium channel blockers]] should be considered in patients who cannot tolerate [[Chronic stable angina treatment beta blockers|beta blockers]] or [[Chronic stable angina treatment nitrates|nitrates]] or who respond inadequately to these drugs. However, [[Chronic stable angina treatment calcium channel blockers|CCBs]] are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release [[nifedipine]], second generation vasoselective calcium channel blockers, and extended-release [[verapamil]] or [[diltiazem]] are the calcium blockers of choice.<ref name="Qaseem">Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012. </ref> | ||
==Symptomatic Relief== | ==Symptomatic Relief== | ||
*The | *The first line therapy consists of the use of [[Chronic stable angina treatment beta blockers|beta blockers]], and if the response to beta blocker therapy is inadequate, [[Chronic stable angina treatment nitrates|nitrates]] may be added. | ||
* For | * For immediate symptomatic relief, sublingal or spray nitroglycerine should be used. | ||
*If angina episodes occur more than 2-3 times in a week, a [[Chronic stable angina treatment calcium channel blockers|calcium channel blocker]] or a [[Chronic stable angina treatment nitrates|long acting nitrate]] may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce [[blood pressure]] and subsequently improve ventricular function. | *If angina episodes occur more than 2-3 times in a week, a [[Chronic stable angina treatment calcium channel blockers|calcium channel blocker]] or a [[Chronic stable angina treatment nitrates|long acting nitrate]] may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce [[blood pressure]] and subsequently improve ventricular function. | ||
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==Chronic Stable Angina: Individual Pharmacologic Agents== | ==Chronic Stable Angina: Individual Pharmacologic Agents== | ||
You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic | You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic: | ||
*Antiplatelet agents: '''[[Chronic stable angina treatment aspirin|Aspirin]] | [[Chronic stable angina treatment dipyridamole|Dipyridamole]] | [[Chronic stable angina treatment clopidogrel|Clopidogrel]]''' | |||
*[[ | |||
*Antianginal agents: '''[[Chronic stable angina nitrate therapy|Nitrates]] | [[Chronic stable angina beta blocker therapy|Beta Blockers]] | [[Chronic stable angina treatment calcium channel blockers|Calcium Channel Blockers]] | [[Chronic stable angina treatment potassium channel openers|Potassium Channel Openers]] | [[Chronic stable angina newer antianginal agents|Newer Anti-anginal Agents]]''' | |||
*[ | |||
*[ | *'''[[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEI/RAAS Blockers]]''' | ||
*[ | *'''[[Chronic stable angina treatment anti-lipid agents|Anti-lipid Agents]]''' | ||
*[ | *'''[[Chronic stable angina guidelines for pharmacotherapy to improve prognosis and reduce symptoms|Guidelines for Pharmacotherapy to Improve Prognosis and Reduce Symptoms]]''' | ||
==References== | ==References== | ||
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{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
[[Category:Disease]] | |||
[[Category:Ischemic heart diseases]] | |||
[[Category:Cardiology]] | |||
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[[Category:Intensive care medicine]] | |||
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[[Category:Up-To-Date cardiology]] | |||
Latest revision as of 20:05, 28 October 2016
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Chronic stable angina medical therapy On the Web | ||
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Risk calculators and risk factors for Chronic stable angina medical therapy | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.; Rim Halaby
Overview
The goal of the management of chronic stable angina is to improve the quality of life by decreasing the severity and frequency of symptoms and to decrease premature cardiovascular death caused by myocardial infarctionn or development of heart failure. The mainstays of the treatment of chronic stable angina are patient education, lifestyle changes and medical therapy.[1] In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term symptom relief is achieved with beta blockers as first line therapy, or calcium channel blockers and long-acting nitrates when beta blockers are contraindicated. Drugs that improve the quality of life and are associated with a better prognosis include: low dose aspirin, beta-blockers and ACEIs.
Medical Therapy
- Lifestyle modification and medical therapy are the first line treatment of patients with chronic stable angina.
Goals of the Medical Therapy
- To decrease premature cardiovascular death:
- By decreasing incidence of myocardial infarction and heart failure
- By increasing survival
- To improve the quality of life:
- By decreasing the severity and frequency of angina
- By increasing exercise tolerance[1]
Management Plan
Shown below is an image illustrating the different components of the management plan of a patient with chronic stable angina:
Patient Education
- Importance of life style changes
- Importance of compliance to medications[1]
Risk Factors Modification
Lipid Profile
- Daily physical activity
- Weight management
- Diet low in saturated fats, trans fat, cholesterol
- Pharmacotherapy with lipid lowering drug therapy ideally HMG-CoA reductase inhibitor to reduce LDL cholesterol level below 100 mg/dl (less than 70 mg/dl in high-risk patients).
Treatment of Hypertension
- Physical activity
- Moderate alcohol intake if any
- Diet low in sodium and rich in fruits, vegetables and low fat dairy products
- Pharmacotherapy with ACEIs and/or beta-blockers
Control of Diabetes
- Glycemic control
Physical Activity
- 30 to 60 minutes of moderate aerobic exercise at least five days a week.
Weight Management
- Target BMI: between 18.5 and 24.9 Kg/m2
- Target waist circumference: less than 40 inches in males and less than 35 inches in females
Smoking Cessation
- Strong recommendation to stop smoking[1]
Contraindicated medications
Angina pectoris is considered an absolute contraindication to the use of the following medications:
Prevention of Acute Coronary Syndrome
Aspirin
- Aspirin (75-162 mg/day) minimizes the risk of thrombosis superimposed on the chronic fixed obstruction.
- Aspirin should be used indefinitely unless contraindicated.
- If Aspirin is contraindicated, the second line treatment is clopidogrel.
Beta Blockers
- Beta blockers reduces heart rate and myocardial oxygen demands, as well as the risk of fatal arrhythmias as a consequence of plaque rupture.
- Beta blockers have shown to prevent ischemia even with a single daily dose and their known long term prognostic benefit may also be generalized to other patients with ischemic heart disease.
- Beta blockers should be used at least three years following myocardial infaction or acute coronary syndrome.
- If left ventricular dysfunction is present, metoprolol, carvedilol or bisoprolol should be used.
ACE Inhibitors
- Strong consideration should be given to the initiation of ACE inhibitors as potential disease modifying therapy.
- ACE inhibitors should be given to almost all patients with chronic stable angina especially in the presence of diabetes, hypertension or chronic kidney disease.
- Calcium channel blockers should be considered in patients who cannot tolerate beta blockers or nitrates or who respond inadequately to these drugs. However, CCBs are not preferred as initial therapy for the management of patients with stable exertional angina. Extended release nifedipine, second generation vasoselective calcium channel blockers, and extended-release verapamil or diltiazem are the calcium blockers of choice.[1]
Symptomatic Relief
- The first line therapy consists of the use of beta blockers, and if the response to beta blocker therapy is inadequate, nitrates may be added.
- For immediate symptomatic relief, sublingal or spray nitroglycerine should be used.
- If angina episodes occur more than 2-3 times in a week, a calcium channel blocker or a long acting nitrate may be added. Regardless of the frequency and severity of angina symptoms, adding a calcium antagonists and/or long lasting nitrates to the main treatment regimen may help to reduce blood pressure and subsequently improve ventricular function.
- In patients with special circumstances or concomitant diseases, specific medications, or combinations of medications are preferable.
- Consider adding a third agent if angina persists despite of two anti-anginal drugs.
- Coronary angiography is indicated in patients with refractory symptoms or ischemia, wherein, administration of optimal medical therapy has failed to control the symptoms or ischemia. Coronary angiography is also indicated in high-risk patients with non invasive test results, and in those with special occupations or sedentary life styles that require a more aggressive approach.
Chronic Stable Angina: Individual Pharmacologic Agents
You can read in greater detail about each of the pharmacotherapy for chronic stable angina below by clicking on the link for that topic:
- Antiplatelet agents: Aspirin | Dipyridamole | Clopidogrel
- Antianginal agents: Nitrates | Beta Blockers | Calcium Channel Blockers | Potassium Channel Openers | Newer Anti-anginal Agents
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.