Angina 181p14

Angina Amareen Bhambra Senior Pharmacist Royal Brompton & Harefield NHS Trust

Aims and objectives  Define

term angina  Understand the different management strategies  Role of pharmacist

Agenda  Angina  Pathogenesis  Risk

factors  Diagnosis  Management  Surgical revascularisation  Secondary prevention

Angina  Coronary

heart disease  Stable angina    

Episodes chest pain Usually predictable Physical exertion Emotional stress

 Unstable  

At rest Sudden

angina

Pathogenesis  Stable 

angina

Stenosed coronary artery unable to meet myocardial oxygen demand = chest pain on exertion

 Unstable 

angina

Progression of atherosclerosis following the rupture of plaque

Risk factors  Modifiable    

Hypertension Smoking Hyperlipidaemia Diabetes

 Non-modifiable   

Age Sex Family Hx

Diagnosis    

Accurate clinical Hx Establish or exclude presence IHD ECG Haemoglobin 

  

Anaemia exacerbate ischaemic chest pain

Thyroid function Fasting glucose Cholesterol 

NICE recommends statin therapy to all high-risk patients regardless of serum cholesterol

Management of angina 

Aim to relieve symptoms and reduce CV risk 





Symptom management – increase oxygen supply by dilating coronary arteries  Sublingual GTN (acute), beta blockers/long-acting nitrates/CCBs Reduce CV risk – smoking cessation, exercise, diet, alcohol consumption, weight and diabetes Prevent future cardiac events

Choice of treatment  Initial

management consists one or two antiangina drugs.  Beta blocker/CCB  If symptoms are not controlled:    

Long acting nitrate Nicorandil Ivabradine Ranolazine

Beta blockers  Reduce

heart rate, blood pressure and contractility of myocardium  Reduction myocardial oxygen demand  Reduce mortality rates  Atenolol, bisoprolol, metoprolol 

Cardioselective

Calcium channel blockers  Modulate

calcium influx into vascular smooth muscle and myocardium = vasodilatory effect  Dihydropyridines – amlodipine  Benzothiapine – diltiazem  Phenylalkylamines - verapamil

Nitrates  GTN  

Denitration releases nitric oxide Dilatation lowers myocardial oxygen requirements

 Sublingual 

GTN

Alleviate immediate symptoms

 Transdermal 

Tolerance

GTN

Long-acting nitrates  ISDN  ISMN  MR

preparations  Compliance  Nitrate free period

Nicorandil  K+

channel activator  Gradual dose titration to minimise side effects  Gastrointestinal ulceration  10mg BD

Ivabradine  Inhibits If channel

in sinus node  Value in patients requiring reduction HR 

Beta blockers rate-controlling CCB are C/I

Licensed chronic stable angina in adults with CAD in normal SR  Combination beta blocker HR >60bpm 





5-7.5mg BD (2.5mg BD elderly)

Side effects: visual symptoms, bradycardia

Ranolazine  Mechanism

not well understood  Improved diastolic function  HR or blood pressure not altered  Side effects – constipation, nausea, dizziness  Interactions – simvastatin  375mg BD, after 2-4 weeks 500mg BD, max 750mg BD

Surgical revascularisation  PCI  Poor

symptom control despite medical treatment  Late stent thrombosis  CABG  Improve survival compared to medical management select cohort patients

Secondary prevention  Aspirin  Statin  Beta

blocker  ACEI

Antiplatelet therapy  Secondary  75mg

prevention

OD  Inhibits COX1 and TxA2 prevents platelet activation and aggregation  Clopridogrel as alternative

Summary  Angina

pain – atherosclerosis  Establish CV history for accurate diagnosis  Management –  

Drug treatment Reduce modifiable risk factors

 Role

of pharmacist

References  NICE

guideline 126. Management of stable angina  Evidence-based Management of Coronary Heart Disease – available via PE  Clinical Pharmacist – Stable angina. Sotiris Antoniou. Jan 2012.  Ben-Dor I, Battler A. Treatment of stable angina. Heart. 2007, 93: 868-874.