Chronic stable angina treatment: Difference between revisions
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{{Chronic stable angina}} | {{Chronic stable angina}} | ||
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto: | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''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.]] | ||
==Overview== | ==Overview== | ||
Treatment of chronic stable angina aims at minimizing symptoms, reducing recurrent [[ischemia]], improving the quality of life and improving [[Chronic stable angina prognosis|prognosis]] by preventing [[MI]] and death. Treatment options include [[Chronic stable angina secondary prevention|lifestyle modification]], [[Chronic stable angina | Treatment of chronic stable angina aims at minimizing symptoms, reducing recurrent [[ischemia]], improving the quality of life and improving [[Chronic stable angina prognosis|prognosis]] by preventing [[MI]] and death. Treatment options include [[Chronic stable angina secondary prevention|lifestyle modification]], [[Chronic stable angina medical therapy|pharmacotherapy]] and [[Chronic stable angina revascularization|revascularization]] that help in slowing the disease progression, preserving the endothelial function and preventing [[thrombosis]]. | ||
Patients with | Patients with [[CAD|single-vessel CAD]] may be started on initial [[Chronic stable angina medical therapy|pharmacologic therapy]] and if non-responsive or symptomatic despite on therapy, [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be a preferred alternative. | ||
Patients with | Patients with [[CAD|double-vessel CAD]] and with [[EF|normal LV function]] may be started on initial [[Chronic stable angina medical therapy|medical management]] and in non-responders, [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be considered. However, the decision of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] versus [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] depends on the coronary anatomy, [[EF|LV function]] and the need for complete revascularization. | ||
Patients with | Patients with [[CAD|triple-vessel CAD]] or [[left main]] [[CAD|disease]] or reduced [[EF|left ventricular function]], [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] is the mainstay of management. However, in cases of mild symptoms or preserved [[EF|LVEF]] in patients with triple-vessel disease, initial [[Chronic stable angina medical therapy|pharmacologic therapy]] or [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] may be tried. | ||
==Precipitating | ==Treatment== | ||
===Precipitating Factors=== | |||
*While chronic stable angina may be due to underlying [[atherosclerosis]], other factors may either precipitate or exacerbate angina. | *While chronic stable angina may be due to underlying [[atherosclerosis]], other factors may either precipitate or exacerbate angina. | ||
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:*[[valvular heart disease|Concomitant valvular heart disease]]. | :*[[valvular heart disease|Concomitant valvular heart disease]]. | ||
==Risk | ===Risk Factor Modification=== | ||
*Initiation of intensive modification of risk factors is an | *Initiation of intensive modification of risk factors is an urgent and essential part of the main therapy in chronic stable angina. | ||
*Initiate risk factor modification, promote regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification. | *Initiate risk factor modification, promote regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification. | ||
*You can read in greater detail about each of the risk factor modification topics below | *You can read in greater detail about each of the risk factor modification topics below: | ||
[[Chronic stable angina treatment smoking cessation|Smoking Cessation]] | [[Chronic stable angina treatment weight management|Weight Management]] | [[Chronic stable angina treatment physical activity|Physical Activity]] | [[Chronic stable angina treatment lipid management|Lipid Management]] | [[Chronic stable angina treatment blood pressure control|BP Control]] | [[Chronic stable angina treatment diabetes control|Diabetes Control]] | [[Chronic stable angina treatment ACC/AHA guidelines for cardiovascular risk factor reduction|ACC/AHA Guidelines for Cardiovascular Risk Factor Reduction]] | |||
:'''[[Chronic stable angina treatment smoking cessation|Smoking Cessation]] | [[Chronic stable angina treatment weight management|Weight Management]] | [[Chronic stable angina treatment physical activity|Physical Activity]] | [[Chronic stable angina treatment lipid management|Lipid Management]] | [[Chronic stable angina treatment blood pressure control|BP Control]] | [[Chronic stable angina treatment diabetes control|Diabetes Control]] | [[Chronic stable angina treatment ACC/AHA guidelines for cardiovascular risk factor reduction|ACC/AHA Guidelines for Cardiovascular Risk Factor Reduction]]''' | |||
==The | |||
Alphabet of chronic stable angina management: | ===The Treatment Essentials=== | ||
Alphabet of chronic stable angina management: Elements listed below are the most important components of stable angina management. | |||
*'''A:''' [[Aspirin]] use | *'''A:''' [[Aspirin]] use | ||
*'''A:''' Anti anginal therapy | *'''A:''' Anti anginal therapy | ||
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*'''E:''' Education | *'''E:''' Education | ||
==Pharmacotherapy== | ===Pharmacotherapy=== | ||
*The role of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and to provide a bettered overall prognosis. | *The role of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and to provide a bettered overall prognosis. | ||
*In patients with chronic stable angina, immediate | *In patients with chronic stable angina, immediate symptomatic relief is achieved with [[Chronic stable angina nitrate therapy|short-acting sublingual nitrates]] and long term relief of symptoms is achieved with [[Chronic stable angina beta blocker therapy|beta blockers]], [[Chronic stable angina treatment calcium channel blockers|calcium channel blockers]] and [[Chronic stable angina nitrate therapy|long-acting nitrates]]. | ||
*Drugs that improve quality of life and are associated with | *Drugs that improve quality of life and are associated with better prognosis include: [[Chronic stable angina treatment aspirin|low dose aspirin]], [[Chronic stable angina treatment angiotensin converting enzyme inhibitors (ACEI) and renin angiotensin aldosterone system blockers (RAAS blockers)|ACEIs]], [[Chronic stable angina beta blocker therapy|beta-blockers]]. | ||
*You can read in greater detail about each of the pharmacotherapies for chronic stable angina below by clicking on the link for that topic | *You can read in greater detail about each of the pharmacotherapies for chronic stable angina below by clicking on the link for that topic: | ||
:*[[Chronic stable angina | :*'''[[Chronic stable angina medical therapy|Overview]]''' | ||
:* | :*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 | :*'''[[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 | :*'''[[Chronic stable angina treatment anti-lipid agents|Anti-lipid Agents]]''' | ||
:*[[Chronic stable angina guidelines for pharmacotherapy to improve prognosis and reduce symptoms|Guidelines for | :*'''[[Chronic stable angina guidelines for pharmacotherapy to improve prognosis and reduce symptoms|Guidelines for Pharmacotherapy to Improve Prognosis and Reduce Symptoms]]''' | ||
==Revascularization== | ===Revascularization=== | ||
*[[Revascularization]] is only used for select patients specially those who have uncontrolled symptoms with optimal medical therapy. | *[[Revascularization]] is only used for select patients specially those who have uncontrolled symptoms with optimal medical therapy. | ||
*This can be achieved with either percutaneous coronary intervention([[PCI]]) with stent placement or [[coronary artery bypass surgery]]. | *This can be achieved with either percutaneous coronary intervention ([[PCI]]) with stent placement or [[coronary artery bypass surgery]]. | ||
:*In general, [[PCI]] is reserved for single or some cases of two vessel disease, and | :*In general, [[PCI]] is reserved for single or some cases of two vessel disease, and | ||
:*[[CABG]] is reserved for patients with two or three vessel disease or left main disease. | :*[[CABG]] is reserved for patients with two or three vessel disease or left main disease. | ||
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*You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic. | *You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic. | ||
[[Chronic stable angina revascularization percutaneous coronary intervention | :'''[[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] | [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] | [[Chronic stable angina percutaneous coronary intervention versus coronary artery bypass grafting|PCI vs CABG]] | [[Chronic stable angina ACC/AHA guidelines for revascularization|ACC/AHA Guidelines for Revascularization]]''' | ||
==Alternative | ===Alternative Therapies for Refractory Angina=== | ||
You can read in greater detail about each of the alternative therapies for refractory angina below by clicking on the link for that topic | You can read in greater detail about each of the alternative therapies for refractory angina below by clicking on the link for that topic: | ||
*'''[[Chronic stable angina transmyocardial revascularization(TMR)|Transmyocardial Revascularization]]''' | |||
*[[ | *'''[[Chronic stable angina spinal cord stimulation(SCS)|Spinal Cord Stimulation]]''' | ||
*'''[[Chronic stable angina enhanced external counter pulsation(EECP)|Enhanced External Counter Pulsation (EECP)]]''' | |||
*'''[[Chronic stable angina ACC/AHA guidelines for alternative therapies in patients with refractory angina|ACC/AHA Guidelines for Alternative Therapies in Patients with Refractory Angina]]''' | |||
*[[ | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WikiDoc Help Menu}} | |||
{{WikiDoc Sources}} | |||
[[Category:Disease]] | |||
[[Category:Ischemic heart diseases]] | [[Category:Ischemic heart diseases]] | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | |||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
[[Category:Up | [[Category:Up-To-Date cardiology]] | ||
Latest revision as of 18:23, 6 February 2013
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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 treatment On the Web | ||
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Risk calculators and risk factors for Chronic stable angina treatment | ||
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; 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.
Overview
Treatment of chronic stable angina aims at minimizing symptoms, reducing recurrent ischemia, improving the quality of life and improving prognosis by preventing MI and death. Treatment options include lifestyle modification, pharmacotherapy and revascularization that help in slowing the disease progression, preserving the endothelial function and preventing thrombosis.
Patients with single-vessel CAD may be started on initial pharmacologic therapy and if non-responsive or symptomatic despite on therapy, PCI may be a preferred alternative.
Patients with double-vessel CAD and with normal LV function may be started on initial medical management and in non-responders, PCI may be considered. However, the decision of PCI versus CABG depends on the coronary anatomy, LV function and the need for complete revascularization.
Patients with triple-vessel CAD or left main disease or reduced left ventricular function, CABG is the mainstay of management. However, in cases of mild symptoms or preserved LVEF in patients with triple-vessel disease, initial pharmacologic therapy or PCI may be tried.
Treatment
Precipitating Factors
- While chronic stable angina may be due to underlying atherosclerosis, other factors may either precipitate or exacerbate angina.
- Identification and management of these conditions may reduce the frequency and intensity of anginal episodes. These conditions include:
- Anemia,
- Uncontrolled hypertension,
- Thyroid disorders (thyrotoxicosis),
- Heart rhythm abnormalities (tachyarrhythmias),
- Decompensated congestive heart failure and
- Concomitant valvular heart disease.
Risk Factor Modification
- Initiation of intensive modification of risk factors is an urgent and essential part of the main therapy in chronic stable angina.
- Initiate risk factor modification, promote regular physical exercise (all patients should be encouraged to obtain 30 to 60 minutes/day of regular aerobic activity), low fat diet, and lifestyle modification.
- You can read in greater detail about each of the risk factor modification topics below:
- Smoking Cessation | Weight Management | Physical Activity | Lipid Management | BP Control | Diabetes Control | ACC/AHA Guidelines for Cardiovascular Risk Factor Reduction
The Treatment Essentials
Alphabet of chronic stable angina management: Elements listed below are the most important components of stable angina management.
- A: Aspirin use
- A: Anti anginal therapy
- B: Beta blocker use
- B: Blood pressure control
- C: Cholesterol lowering therapy
- C: Cigarette smoking cessation
- D: Diabetes Mellitus control
- D: Diet
- E: Exercise
- E: Education
Pharmacotherapy
- The role of pharmacotherapy in the management of chronic stable angina is to reduce the severity and frequency of symptoms and to provide a bettered overall prognosis.
- In patients with chronic stable angina, immediate symptomatic relief is achieved with short-acting sublingual nitrates and long term relief of symptoms is achieved with beta blockers, calcium channel blockers and long-acting nitrates.
- Drugs that improve quality of life and are associated with better prognosis include: low dose aspirin, ACEIs, beta-blockers.
- You can read in greater detail about each of the pharmacotherapies 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
Revascularization
- Revascularization is only used for select patients specially those who have uncontrolled symptoms with optimal medical therapy.
- This can be achieved with either percutaneous coronary intervention (PCI) with stent placement or coronary artery bypass surgery.
- With the availability of drug-eluting stents, PCI is increasingly being performed for many lesions including more complex ones.
- You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic.
Alternative Therapies for Refractory Angina
You can read in greater detail about each of the alternative therapies for refractory angina below by clicking on the link for that topic:
- Transmyocardial Revascularization
- Spinal Cord Stimulation
- Enhanced External Counter Pulsation (EECP)
- ACC/AHA Guidelines for Alternative Therapies in Patients with Refractory Angina