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Angina, Stable

Aspirin and antianginal therapy β-Blocker and BP Cigarette smoking and cholesterol Diet and diabetes Education and exercise Issues for Referral

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Issues for Referral

  • Elderly: Special attention to medication side effects, drug interactions, comorbidities
  • ACC/AHA recommends follow-up evaluation by a cardiologist every 4-12 mo in the 1st yr after initial presentation and treatment
  • After the 1st yr, if the patient is aware of symptoms, yearly follow-up is appropriate
  • Differential diagnosis of anginal symptoms must be considered (coronary artery dissection, pulmonary embolism, etc.).
  • Symptoms may increase with hemodynamic changes.

Considerations in Women

  • Many women note more atypical symptoms, or are asymptomatic.
  • Microvascular dysfunction prevalent in women and may explain paradox of symptoms and signs of ischemia without obstructive coronary disease.
  • Premature disease in women may be related to estrogen deficiency.

Suspect familial dyslipidemia or arteritis (Kawasaki disease)

Additional Therapies

  • Cardiac rehabilitation
  • Oxygen therapy
  • Co-enzyme Q10
  • Relaxation techniques/acupuncture/yoga

Surgery

  • Medical therapy as effective as percutaneous transluminal angioplasty (PCI) for death, MI outcome; PCI does not improve survival.
  • Neither PCI nor coronary artery bypass grafting (CABG) decreases reinfarction.
  • Stable angina refractory to medical therapy may benefit from revascularization.

In-Patient Considerations

Initial-Stabilization

  • Sublingual nitroglycerin every 5 min for a total of 3 doses
  • Activation of EMS if pain ongoing

Admission Criteria

  • Pain not relieved in 30 min of initial treatment merits hospitalization for further evaluation
  • ECG changes or arrhythmia
  • Positive cardiac biomarkers

IV Fluids

Only if patient is hypotensive

Discharge Criteria

  • Ruled out for acute coronary syndrome by lab tests, ECG, and no abnormal imaging
  • No chest pain for previous 24 hr

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

  • Every 4-12 mo with ECG
  • Testing with changes in clinical status: Echo for new or worsening valvular heart disease Treadmill exercise or pharmacologic stress ECG if no prior revascularization Stress imaging if prior revascularization
  • Coronary angiography if marked limitation of ordinary activity (CCS class III) despite maximal medical therapy

Diet

  • Low-cholesterol, low-fat diet (general population) 2 g sodium diet (hypertensives)
  • Weight management

Patient Education

  • Educate in format in which they learn best.
  • Utilize ancillary staff and patient educators.
  • Involve family members.
  • Remind, repeat, and reinforce.

Prognosis

Overall annual mortality rate 3-4%

Complications

  • MI
  • Arrhythmia
  • Mitral regurgitation
  • Sudden death
  • Depression

Additional Reading

1

Abrams J.

Chronic stable angina. N Engl J Med. 2005;352:2524-2533. [View Abstract] 2

ACC/AHA/2002 Guideline update for the management of patients with chronic stable angina. J Am Coll Cardiol. 2003;41:159-168. 3

Boden WE. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007;356:1503-1516. [View Abstract] 4

Heidenreich PA. Meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina. JAMA. 1999;281:1927-1936. [View Abstract] 5

Johnson BD, et al.

Prognosis in women with myocardial ischemia in the absence of obstructive coronary disease. Results from the National Institutes of Health-National Heart, Lung and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE.)

Circulation

2004;109:2993-2999. [View Abstract] 6

Morrow DA, Gersh BJ, Braunwald E.

Chronic coronary artery disease. In: Braunwald's Heart Disease, 7th ed.Philadelphia: Saunders, 2005:1281-1308. 7

Pfisterer ME. Therapies for Type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360:2503-2515.

Codes

ICD9

413.9 Other and unspecified angina pectoris

SNOMED

  • 233819005 stable angina (disorder)
  • 429559004 typical angina (disorder)
  • 371807002 atypical angina (disorder)

Clinical Pearls

  • Risk-factor modification is vital to preventing and controlling stable angina.
  • The options for treatment of stable angina include medical therapy, lifestyle changes and revascularization (PCI, CABG).