Stable Angina

Stable angina
Introduction
 Angina pectoris is the symptom complex caused by transient myocardial

ischaemia and constitutes a clinical syndrome rather than a disease. It may
occur whenever there is an imbalance between myocardial oxygen supply and
demand
 Coronary atheroma is by far the most common cause of angina, although the
symptom may be a manifestation of other forms of heart disease, particularly
aortic valve disease and hypertrophic cardiomyopathy
Clinical features
 Stable angina is characterised by central chest pain, discomfort or
breathlessness that is precipitated by exertion or other forms of stress, and is
promptly relieved by rest
 Some patients find the discomfort comes when they start walking, and that
later it does not return despite greater effort and this is called “warm-up
angina”
 Physical examination is frequently unremarkable but should include a careful
search for evidence of valve disease particularly aortic, important risk factors
e.g.hypertension, diabetes mellitus, left ventricular dysfunction
cardiomegaly, gallop rhythm, other manifestations of arterial disease such as
carotid bruits, peripheral vascular disease and unrelated conditions that may
exacerbate angina including anaemia and thyrotoxicosis
Investigations
 Resting ECG - The ECG may show evidence of previous MI but is often normal,
even in patients with severe coronary artery disease. Occasionally, there is T-
wave flattening or inversion in some leads, providing non-specific evidence of
myocardial ischaemia or damage. The most convincing ECG evidence of
myocardial ischaemia is the demonstration of reversible ST segment depression
or elevation, with or without T-wave inversion, at the time the patient is
experiencing symptoms whether spontaneous or induced by exercise testing
 Exercise ECG - An exercise tolerance test (ETT) is usually performed using a
standard treadmill or bicycle ergometer protocol while monitoring the
patient’s ECG, BP and general condition. Planar or down-sloping ST segment
depression of 1 mm or more is indicative of ischaemia. Up-sloping ST
depression is less specific and often occurs in normal individuals. Exercise
testing is also a useful means of assessing the severity of coronary disease and
identifying high-risk individuals. For example, the amount of exercise that can
be tolerated and the extent and degree of any ST segment change provide a
useful guide to the likely extent of coronary disease. Exercise testing is not
infallible and may produce false-positive results in the presence of digoxin
therapy, left ventricular hypertrophy, bundle branch block or WPW syndrome
 Myocardial perfusion scanning - This may be helpful in the evaluation of
patients with an equivocal or uninterpretable exercise test and those who are
unable to exercise
 Stress echocardiography - This is an alternative to myocardial perfusion
scanning and can achieve similar predictive accuracy. It uses transthoracic
echocardiography to identify ischaemic segments of myocardium and areas of
infarction
 Coronary arteriography - This provides detailed anatomical information about
the extent and nature of coronary artery disease, and is usually performed
with a view to coronary artery bypass graft (CABG) surgery or percutaneous
coronary intervention (PCI). In some patients, diagnostic coronary
angiography may be indicated when non-invasive tests have failed to establish
the cause of atypical chest pain. The procedure is performed under local
anaesthesia and requires specialized radiological equipment, cardiac
monitoring and an experienced operating team
Management: general measures
 The management of angina pectoris involves:

• A careful assessment of the likely extent and severity of arterial disease
• The identification and control of risk factors such as smoking, hypertension and
hyperlipidaemia
• The use of measures to control symptoms
• The identification of high-risk patients for treatment
to improve life expectancy
 Management should start with a careful explanation of the problem and a
discussion of the potential lifestyle and medical interventions that may
relieve symptoms and improve prognosis. Anxiety and misconceptions often
contribute to disability; for example, some patients avoid all forms of
exertion because they believe that each attack of angina is a ‘mini heart
attack’ that results in permanent damage. Effective management of these
psychological factors can make a huge difference to the patient’s quality of
life
 Advice to patients with stable angina:
Do not smoke
Aim for ideal body weight
Take regular exercise - exercise up to, but not beyond, the
point of chest discomfort is beneficial and may promote
collateral vessels)
Avoid severe unaccustomed exertion, and vigorous exercise
after a heavy meal or in very cold weather
Take sublingual nitrate before undertaking exertion that may
induce angina

Stable Angina

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Stable angina

 Angina pectoris is the symptom complex caused by transient myocardial

 The management of angina pectoris involves:

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