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Aspirin and antianginal therapy β-Blocker and BP Cigarette smoking and cholesterol Diet and diabetes Education and exercise
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).