Stable Angina

Warning:

• Angina is only one manifestation of coronary insufficiency (which may itself be the cause of ischemic heart failure, myocardial infarction, arrhythmia supraventricular and ventricular, or sudden death).

• Ischemia can be painless, “silent” (the symptoma¬tologie is unfaithful).

• Interest additional tests such as stress testing and stress echo to assess the existence and extent of ischemia (ischemic threshold), except in cases of unstable angina.

• The treatment of angina is symptomatic and etiological, and must include the secondary prevention of cardiovascular events in the fight against risk factors.

• The combination of several anti-anginal requires specialist advice.

• The indication for coronary angiography should be discussed with the specialist.

• The “intervention” cardiology (angioplasty, implantation of a coronary stent) is part of the therapeutic arsenal, and revascularization surgery.

• Treatment is BASIC: Beta-blocker antiplatelet + + + Statin inhibitor of the renin-angiotensin system + Control of risk factors.

Additional clinical and examinations:

Functionally, typically: constrictive retrosternal pain or burning bar, radiating to the jaw or left arm (inside), brought on by exercise (walking and / or cold and / or digestion and / or emotion) gradually giving way to stopping it, or within minutes after sublingual nitroglycerin (bitten or sprayed).

Atypical forms: blockpnée painless, epigastric pain, or reduced to radiation, angina syncopal (arrhythmia) or primodécubitus.

Risk factors making it more likely diagnosis: age> 60 years, coronary heredity, hypertension, dyslipidemia (high total cholesterol, high LDL cholesterol, low HDL-cholesterol), smoking, diabetes, abdominal obesity, physical inactivity, …

Physical examination: search valvular disease (ischemic mitral regurgitation, aortic stenosis), another peripheral arterial disease (lower extremity, aorta, renal, carotid).

ECG almost always normal outside ++ crises, may show necrosis sequel, a conductive disorder, sometimes permanent disturbances of repolarization (ST, T). In crisis, subendocardial injury (in ST segment elevation), sub-epicardial ischemia (negativation T), rarely lesion subepicardial (ST segment elevation) of angina spastic angina (or the IDM in the Making it does not regress after TNT, requiring emergency call SAMU).

ECG: unless unstable angina, outflow obstruction VG (tight aortic stenosis, obstructive cardiomyopathy: interest prior ++ echocardiography in doubt if systolic murmur ++), severe uncontrolled hypertension, disorders of severe spontaneous ventricular rhythm, heart failure … Interest of the test cleansed if possible (temporary cessation of bradycardia drugs). Prefer the treadmill, particularly in women or sedentary as possible to achieve significant heart rate much more easily (85% of 220-age). Cleansed, this examination allows the diagnosis, assessment of severity (ischemic threshold, time to recovery of the basic course, arrhythmias), and in treatment or after angioplasty, assessment of treatment efficacy.

Myocardial stress scintigraphy under dipyridamole or (in case of impossibility of effort) more sensitive than the ECG, allows the diagnosis in doubtful cases (women ++) and especially the location of the ischemic territory (thus indirectly / officials coronary).

Stress Echocardiography (effort or dobutamine): Alternative to scan, compared with the echo images at rest, stress can show a localized kinetic anomaly, confirming the ischemia diagonstic ++ and ++ territory.

Coronary angiography: less traumatic (radial approach, finer probes), indicated if revascularization is possible: young subject and / or assets, angina disabling, ischemic low threshold, aortic valve disease, unstable angina … This examination stock ++ specific lesion but does not provide evidence of ischemia (the evidence of ischemia is clinical and / or electrical and / or scintigraphic and / or echocardiography).

Coronary Angio-CT: this examination more efficient (64-slice scanner) is mainly indicated in screening patients for whom the probability of coronary artery disease is moderate to low, with symptoms suggestive and / or ECG inconclusive . It avoids the “normal” coronary angiograms made by arterial route. That said, for this review, the heart must be slowed so bêtabloqué most often, some images are difficult to interpret (in case of calcified lesions), and the irradiation is the same as a conventional coronary angiography.

Treatment of stable angina:

The treatment is “BASIC”: A + B êtabloquant ntiagrégant platelet + S + I tatin nhibiteur the renin-angiotensin system +C ontrol risk factors.

Fight against the risk factors +++

– Stop smoking.

– Reduced weight through proper diet.

– Hypercholesterolemic: PRAVASTATIN or SIMVASTATIN or LESCOL or TAHOR or Crestor, the target being to achieve an LDL cholesterol <1g / l +++. The use of INEGY 20 or 40 mg (Association simvastine 20 or 40 mg + ezetimibe) provides interesting figures avoiding increasing statin doses, which often gives more myalgia.

– Equilibration of hypertension, diabetes.

– Fight against inactivity.

Beta-blockers:

– Used as first-line angina of effort or mixed.

– Chronotropic effect and negative inotropic.

– Effective beta blockade if pulse less than 60 / min.

– Never stop abruptly (rebound ++).

– Prefer cardioselective beta blockers SECTRAL, Tenormine, Kerlone, SOPROL or DETENSIEL, SELOKEN, CELECTOL, and distinguish between those with intrinsic sympathomimetic activity (ISA) as SECTRAL or CELECTOL and those without UPS as Tenormine, Kerlone, SOPROL, DETENSIEL and SELOKEN more bradycardia.

– Contraindications: preexisting bradycardia, AV block II, unbalanced heart failure, peripheral arterial disease with severe ischemia, obstructive pulmonary disease, Raynaud’s syndrome.

The existence of a moderate pulmonary disease or severe arterial disease must prefer celiprolol (CELECTOL).

– Caution when combined with bradycardi¬santes molecules (diltiazem, digoxin, amiodarone …).

Ivrabradine:

– Ivabradine (PROCORALAN) only works by reducing the heart rate by selective and specific inhibition of the cardiac pacemaker I f current that controls the spontaneous diastolic depolarization in the sinus node and regulates heart rate.

– The cardiac effects are specific to the sinus node with no effect on intra-atrial conduction time, atrioventricular or intraventricular, on myocardial contractility or ventricular repolarization.

– This medicine is an alternative if absolutely against-indication to beta-blockers.

– In case of intolerance to beta-blocker will reduce the dose of beta-blocker, avoiding as possible to stop completely, and prescribe the PROCORALAN 5mg in 2 doses (2.5 mg in the elderly), for starters.

– We will prescribe PROCORALAN if resting heart rate is above 70 / min under a beta blocker dose considered suitable (the maximum dose tolerated by the patient), as this too high heart rate is a poor prognostic factor for coronary.

Angiotensin converting enzyme:

– Triatec Prescribing (assembly if possible up to 10 mg / day) or COVERSYL (if possible to mount up to 10 mg / day) is recommended, regardless of blood pressure numbers. At these doses, they have led to a reduction in cardiovascular morbidity and mortality in coronary.

Calcium antagonists:

– Distinguish those bradycardia (MONOTILDIEM, Isoptine) and those who have a neutral effect on the FC (AMLOR, FLODIL): Possible monotherapy, those who are a little tachycardisants (ADALATE, CHRONADALATE) used first only intention if angina spastic, but always in combination with beta-blockers in case of stable angina of effort or lack of efficacy.

– Careful with bradycar¬disantes molecules when used in combination.

– Negative inotropic effect especially with verapamil (cons-indicated if heart failure).

– Classic Side effects: flushes, headache, edema of the lower extremities especially with the dihydropyridine.

Potassium channel activators:

– Direct Action coronary vasodilator, no flight effect; coronary spastic action.

– Action peripheral arterial and venous vasodilator.

– No exhaust, no negative inotropic effect.

– Preferably, do not associate with nitro nor molsidomine.

– Determination at 10 and 20 mg, 2 times daily, but start to 5 mg 2 times per day (possible headache).

Nitrates:

– Basic salary of angina attack, sublingual (aerosol or PC).

– Decrease preload, cause coronary vasodilation, arterial and venous.

– Contraindications: glaucoma, hypotension, obstructive cardiomyopathy.

– Delivered orally (usually prolonged-release tablet in 1 or 2 daily dose according to the molecule) or transdermal (patch 5, 10 or 15 mg), but anyway principle of therapeutic window: stop 8 hours a day, to avoid habituation, usually at night. Corollary: If frequent angina, choose the schedule of the window and cover

this window by another medicine orally, thus associating the nitro to another drug.

– Possibility of headache that may be discontinued.

Molsidomine:

– Action of the type of nitrates.

– But no therapeutic escape ++.

– Oral administration in 3 doses daily.

– Dosage 2 mg and 4 mg.

Trimetazidine:

– Prophylactic treatment of angina crisis.

– Action with metabolic cell protective effect during hypoxia and ischemia phases.

– In combination, administration 2 a day.

Types of orders:

The prescription of a statin is systematic +++ (pravastatin, simvastatin, FRACTAL [fluvastatin] TAHOR [atorvastatin]Crestor [rosuvastatin].

Consider if the coronary ischemic threshold is low despite medical treatment or if the patient remains disabled (interest of effort under treatment ischemia testing).

– But in general, consider coronary angiography if the patient has a life expectancy correct, not to miss lesions revascularization within +++ will improve morbidity and mortality +++ trunk stenosis common proximal stenosis of the LAD artery (anterior) or tri-truncal injuries. In other types of injuries, especially revascularization improve the quality of life, reducing crises.

Order No. 1: stable angina of effort or very little moderately disabling

– KARDEGIC [lysine acetylsalicylate] 75 or 160 mg

– Tenormine 100 [atenolol] or DETENSIEL [bisoprolol] or Kerlone [bétaxodol chloride]: 1 PC awakening, or SECTRAL 200 [Acebutolol] or CELECTOL [celiprolol]: 1 tablet morning and night orAMLOR [amlodipine] 1 tablet per day .

– In case of intolerance of beta-blockers, reduce the dose of it and prescribe PROCORALAN 5 mg: 1 tablet morning and night, to climb PROCORALAN 7.5 mg: 1 tablet morning and evening (with ECG control).

– Even if attitude against-indication to beta blockers: PROCORALAN 5 mg and 7.5 mg

– Statin: ELISOR [pravastatin] 40 mg: 1 tablet per day (or better: PRAVADUAL 1 tablet per day = pravastatin + aspirin) or TAHOR [atorvastatin] 10 mg: 1 tablet per day or Crestor [rosuvastatin] 5 mg: 1 tab daily.

– COVERSYL [perindopril] 2.5 mg, 1 tablet per day, up to several weeks to 10 mg per day (in theory).

– Vastarel [trimetazidine] 35 mg, 2 tablets per day in additional treatment in non revascularisables case.

– NATISPRAY [NTG] 0.15 mg: 1 bottle to keep with you; 2 puffs if sublingual pain (then sit).

Ordinance No. 2: stable angina of effort resistant to monotherapy

– KARDEGIC [lysine acetylsalicylate] 75 or 160 mg / day.

– Dual therapy preferably comprising a beta-blocker (DETENSIEL [bisoprolol] … see above):

– With ADANCOR [nicorandil] 10 or 20 mg 2 tablets per day,

– With AMLOR [amlodipine] 1CP per day,

– With CORVASAL [molsidomine] 2mg 3 tab daily,

– With a nitroglycerin patch 5 or 10 mg: DISCOTRINE [NTG]

– Or MONOTILDIEM LP 300 [diltiazem chloride], 1 a day with CORVASAL [molsidomine] or nitro or Vastarel [trimetazidine], 35 mg, 2 tablets per day,

– NATISPRAY [NTG] 0.30 mg: 2 puffs if sublingual pain.

– Statin ditto: ELISOR 40 mg or 10 mg TAHOR.

– IEC: ditto: COVERSYL 2.5 mg or 5 mg.

No.3: pure spastic angina

– KARDEGIC [lysine acetylsalicylate] 160 mg / day.

– Beta-blockers against-indicated.

– MONOTILDIEM LP [diltiazem chloride] 300 mg per day or 1 AMLOR [amlodipine] 1 a day.

– Possibly associated DISCOTRINE [NTG] 5 mg.

– NATISPRAY [NTG] 0.30 mg.

Ordinance No. 4: after angioplasty

– In the absence of stent (rare): KARDEGIC [lysine acetylsalicylate] 75 to 160 mg per day.

– If stenting “not active”, “naked” PLAVIX (irreplaceable), 1 tablet daily with KARDEGIC 75 mg / day for 1 month, then chooses one of the two drugs.

– If stenting “active” PLAVIX (irreplaceable), 1 tablet daily with KARDEGIC 75 mg / day, all for 12 months; attention to the risk of late thrombosis acute, often fatal during this period, if possible postpone any surgery or hemorrhagic gesture, rather than stopping these drugs unnecessarily! Seek the advice of a specialist. After this period, we continue with one of the two drugs.

– Work stopping.

– The rest of the treatment is to discuss with the cardiologist, ischemia testing (stress eg ECG) is usually scheduled before the fourth month.