Angina Pectoris

Aka: Angina Pectoris, Angina, Myocardial Ischemia, Ischemic Heart Disease, Stable Angina, Antianginal

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II. History

  1. See Chest Pain
  2. Ask Exercise History
  3. How often do you take Nitroglycerin?
  4. Documentation: Problem Summary
    1. History of Myocardial Infarction
    2. Ejection Fraction
    3. Revascularization procedures
    4. Angina (stability, severity, ischemic equivalents)
    5. Stress tests and imaging
    6. Secondary prevention goals at target?

III. Symptoms

  1. See Chest Pain

IV. Diagnosis

  1. See Angina Diagnosis

V. Types: Angina

  1. Chronic Angina (Fixed Obstruction)
    1. Resting Angina: 90% stenosis
    2. Pretreat higher endurance activities
      1. Take Nitroglycerin sublingual before activity
  2. Unstable Angina (Plaque rupture)
    1. Myocardial Infarction high risk
      1. Often occurs with 2 weeks of symptom onset
  3. Vasospastic Angina (Prinzmetal's Angina)
    1. See Vasospastic Angina

VI. Labs: Biomarkers of chronic disease

  1. NT-proBNP
    1. Confers >5 fold risk of mortality if increased
  2. hs-CRP
    1. Confers up to 1.3 risk of coronary disease
  3. References
    1. Ndrepepna (2005) Circulation 112:2102-2107 [PubMed]

VII. Management: Non-Pharmacologic

  1. Mental Stress confers Myocardial Ischemia risk
    1. Decreases Left Ventricular Ejection Fraction
    2. Doubles the risk of ischemic complications
  2. References
    1. Jiang (1996) JAMA 275:1651-6 [PubMed]

VIII. Management: Pharmacologic (Mechanisms of action)

  1. Nitroglycerin
    1. Reduces Preload, reduces Afterload, dilates collaterals
    2. Increases Exercise tolerance and time to Angina onset in those with Stable Angina
  2. Beta Blocker
    1. Reduces Heart Rate, reduces Afterload, decreases cardiac contractility
    2. Improves survival and decreases MI recurrence following recent MI or LV dysfunction
    3. Decreases Angina frequency and increases treadmill time
    4. Contraindications
      1. Decompensated Congestive Heart Failure (CHF)
      2. Do not combine with Calcium Channel Blockers (risk of AV Block)
  3. Calcium Channel Blocker
    1. Reduces Afterload, prevents Vasoconstriction (no significant effect on vasodilatation)
    2. Short acting Dihydropyridines (e.g. Nifedipine) may paradoxically increase cardiovascular event rate
    3. Effective Antianginals, but do not decrease mortality
      1. Bangalore (2009) Am J Med 122(4): 356-65 [PubMed]
  4. Aspirin (or other antiplatelet agents)
    1. Decreases Platelet aggregation
    2. Reduces cardiovascular event rate in Angina patients by one third

IX. Management: Protocol

  1. Step 1
    1. Aspirin 81 mg daily (or Platelet ADP Receptor Antagonist if Aspirin contraindicated)
    2. Sublingual Nitroglycerin prn and before Exercise
    3. Beta Blocker (e.g. Metoprolol)
  2. Step 2
    1. Increase Beta Blocker dose OR
    2. Consider Isosorbide monohydrate XR (once daily, least expensive long acting nitrate)
  3. Step 3
    1. Consider adding Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine), if no Systolic Dysfunction
  4. Step 4 (Refractory Angina)
    1. Consider Stress test or angiography again if need >2 agents
    2. Revascularization may be needed
      1. CABG is indicated in multi-vessel disease, Diabetes Mellitus, >50% left main Coronary Artery
      2. PCI may improve symptoms but does not reduce mortality in stable coronary disease
        1. May be preferred in Stable Angina when Antianginals are not tolerated or taken consistently
        2. Rajkumar (2023) N Engl J Med 389(25): 2319-30 [PubMed]

X. Management: Other measures

  1. Ranolazine (Ranexa)
    1. Not more effective than other anti-Anginal medications
    2. Risk of QT Prolongation, multiple Drug Interactions and high expense (>$500/month)
    3. Used in combination with other agents above
    4. Reduces Angina frequency (by one less episode/week)
    5. Chaitman (2004) JAMA 291:309-16 [PubMed]

XI. Management: Comorbidity

  1. Major Depression
  2. Obstructive Sleep Apnea
  3. Obesity
  4. Cerebrovascular Disease symptoms
  5. Peripheral Vascular Disease

XII. Management: Patient Instructions

  1. Rehearse what to do:
    1. Chest Pain
      1. Take one Nitroglycerin sublingually at onset
      2. Chew one Aspirin 162 to 325 mg (in whom there is no contraindication)
      3. Seek immediate medical attention if symptoms worsen or do not improve within 5 minutes
      4. Continue to take Nitroglycerin every 5 minutes up to a total of 3 doses as needed for Chest Pain
    2. Transient Ischemic Attacks or Cerebrovascular Accident
      1. Immediate emergency department evaluation
  2. Review Prevention
    1. See Cardiac Risk Reduction
    2. Increase activity
    3. Omega-3-Fatty Acids as of 2021 do not appear to significantly lower Cardiovascular Risk
      1. (2021) Presc Lett 28(1): 1-2
      2. Nicholls (2020) JAMA 324(22):2268-80 [PubMed]
  3. Testing (review if current, esp. if high risk)
    1. Stress Testing every 3-5 years
    2. Coronary Artery Disease Biomarkers (see above) every 3-5 years
    3. Secondary prevention labs
      1. Lipid profile
      2. Hemoglobin A1C
  4. Review Goals
    1. Blood Pressure <130/80
    2. LDL Cholesterol <70-100 mg/dl
    3. HDL Cholesterol >45 mg/dl
    4. Body Mass Index optimization
    5. Hemoglobin A1C < 7.0
  5. Review Medications
    1. Aspirin
    2. ACE Inhibitor
    3. Beta Blocker
    4. Antianginals
  6. Follow-up
    1. Primary care visits every 6 months if stable
    2. Cardiology every 1-2 years
  7. Handouts
    1. Updated medication list and after visit summary
    2. Mediterranean Diet

XIII. References

  1. Braun (2018) Am Fam Physician 97(6): 376-84 [PubMed]
  2. Fihn (2012) Circulation 126(25): 3097-137 [PubMed]

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