Stable IHD: angina Pectoris

Dr. Nasih Abdulla

Interventional cardiologist
A 55-year-old male patient comes in for a routine health
check-up. He has a history of hypertension but no other
significant medical issues. He reports no symptoms such as
chest pain, shortness of breath, or fatigue. Routine blood tests
reveal elevated cholesterol levels, and a coronary angiogram
shows significant plaque buildup in the coronary arteries.
Despite these findings, the patient remains asymptomatic.
Given the presence of significant plaque buildup in the coronary
arteries, the patient:
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• A) Must be symptomatic
• B) Cannot be symptomatic
• C) May be asymptomatic
• D) Cannot be asymptomatic
A 55-year-old male patient comes in for a routine health
check-up. He has a history of hypertension but no other
significant medical issues. Recently, he has started
experiencing mild chest discomfort when walking upstairs,
which subsides with rest. Routine blood tests reveal elevated
cholesterol levels, but no coronary angiogram has been
performed yet. The patient reports that the discomfort is only
present during physical exertion, such as climbing stairs, and
he has no symptoms at rest.
Given the patient’s symptoms of chest discomfort during
exertion, what is the most likely diagnosis?

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• A) Gastroesophageal reflux disease (GERD)
• B) Stable angina pectoris
• C) Acute coronary syndrome
• D) Pulmonary embolism
A 55-year-old male patient, who was previously diagnosed
with stable angina pectoris and advised to start treatment,
returns to the clinic. He did not follow the recommended
treatment plan. Over the past few weeks, he has experienced
worsening symptoms, including severe, central chest pain that
occurs with minimal exertion, such as during daily home
activities like walking around the house or doing light chores.
The pain typically lasts for about 10 minutes and subsides with
rest, but it is becoming more frequent and intense.
Has the patient’s condition likely progressed since the initial
diagnosis?
Yes or No?
Given the patient’s worsening symptoms, what is the most likely
diagnosis now?

• A) Gastroesophageal reflux disease (GERD)

• B) Unstable angina
• C) Pulmonary embolism
• D) Musculoskeletal pain
Which of the following best describes the spectrum of clinical
presentations for coronary artery atherosclerosis?

• A) It always causes severe chest pain (angina).

• B) It can range from no symptoms (asymptomatic) to severe
complications like myocardial infarction.
• C) It only presents with symptoms during physical activity.
• D) It exclusively causes shortness of breath.
 DD:
• 1. Unstable Angina/Non-ST Elevation
Myocardial Infarction (NSTEMI): Unlike
stable angina, symptoms occur at rest, are new
in onset, or represent a change from the typical
pattern. May not have diagnostic changes on
an initial ECG or biomarkers.
•
• 2. Gastroesophageal Reflux Disease
(GERD): Burning or discomfort in the chest,
which may be related to meals or lying down,
 can mimic angina but is due to acid reflux.

4. Costochondritis: Inflammation of the rib cage joints can cause

chest pain upon palpation or movement, which is not related to
exertion.

5. Pericarditis: Inflammation of the pericardium, presenting with

sharp chest pain that may change with position and is typically
relieved by sitting up and leaning forward.

6. Aortic Stenosis: This valvular heart disease can cause chest

pain on exertion due to obstruction of blood flow from the left
ventricle, but it is usually accompanied by a heart murmur.
7. Hypertrophic Cardiomyopathy: Can cause exertional chest
pain due to the thickened heart muscle's increased oxygen
demand, often with a murmur or other signs on examination.

8. Pulmonary Embolism: Sudden onset of chest pain, typically

associated with shortness of breath or hemoptysis; however,
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chronic thromboembolic disease can cause exertional chest pain.

9. Pulmonary Hypertension: Exertional chest discomfort due to

increased pressure in the pulmonary arteries; often accompanied
by fatigue and dyspnea.
10. Pneumothorax: Sudden onset of sharp chest pain and
shortness of breath due to collapsed lung; not typically
related to exertion.
11. Panic Disorder/Anxiety: Can cause chest discomfort,
palpitations, and shortness of breath mimicking angina but
are often associated with feelings of panic and other systemic
symptoms.
12. Musculoskeletal Disorders: Strains or sprains of the
chest wall muscles or ribs can cause pain that may be
confused with angina but are typically reproducible with
movement or palpation.
13. Peptic Ulcer Disease: Epigastric pain which may radiate
to the chest, mimicking angina, often related to meals or
relieved by antacids.
The most common presentation of CAD is stable
angina pectoris: Chest pain, pressure , or discomfort
they develops with exertion and is relieved with rest

The symptoms occur when atherosclerotic plaque

limits coronary blood flow and result in imbalance
between supply and demand.
Angina occurs when there is an imbalance between the oxygen
supply to the heart muscle (myocardium) and its demand. Decreased
oxygen supply to the myocardium is one of the key factors that can
lead to angina.
1. Atherosclerosis of the Coronary Arteries:Coronary Artery Disease
(CAD): The most common cause, where atherosclerotic plaques
narrow the coronary arteries, reducing blood flow and, therefore,
oxygen supply to the heart muscle.
2. Coronary Artery Spasm:Prinzmetal’s Angina: Sudden, transient
constriction of the coronary arteries (vasospasm) can significantly
reduce blood flow, even in the absence of significant atherosclerosis.
3. Thrombus Formation:Coronary Thrombosis: A blood clot can
form on a ruptured atherosclerotic plaque, leading to a sudden and
critical reduction in blood flow.
4. Coronary Embolism:Embolism: A blood clot or other embolic
material can travel to and block a coronary artery, decreasing the
blood supply to the heart muscle.
5. Severe Aortic Stenosis:Aortic Valve Narrowing: Significant
narrowing of the aortic valve reduces the outflow of blood from the
heart, lowering the overall blood supply to the coronary arteries.
6. Anemia:Severe Anemia: Reduced hemoglobin levels in the
blood decrease the oxygen-carrying capacity, limiting the oxygen
supply to the myocardium even if coronary arteries are normal.
7. Hypoxemia:Low Blood Oxygen Levels: Conditions that cause low oxygen
levels in the blood, such as severe lung disease or high altitude, can reduce
the oxygen supply to the heart.
8. Coronary Microvascular Dysfunction:Microvascular Angina: Dysfunction
in the small coronary vessels can impair blood flow to the myocardium,
reducing oxygen supply even if the major coronary arteries are not
significantly narrowed.
9. Decreased Coronary Perfusion Pressure:Hypotension: Low blood pressure
can reduce the pressure gradient that drives blood flow through the coronary
arteries, decreasing myocardial oxygen supply.
10. Tachyarrhythmias:Rapid Heart Rates: Excessively fast heart rates can
reduce the time available for coronary blood flow during diastole, decreasing
oxygen supply to the heart muscle.
11. Carbon Monoxide Poisoning
Causes of Increased Myocardial Oxygen Demand Leading to
Angina:
1. Physical exertion
2. Tachycardia
3. Hypertension
4.Left ventricular hypertrophy (LVH)
5.Severe aortic stenosis
6. Emotional stress
7. Fever , Hyperthyroidism, Cold exposure
8. Postprandial state (after meals)
9 Cocaine use
 Typical angina chest pain has three components:
1. Substernal chest pain or discomfort,
2. provoked by exertion or stress and
3. relieved by rest or GTN

Atypical angina chest pain has two components

Non angina chest pain has one or none of the
components
 Diagnosis and evaluation
Depends on:
CVD risk factors
Chest pain
Age and sex
These factors used to differentiate angina from
other causes of chest pain and used to
determine patient’s pretest likelihood of CAD
Pretest likelihood of CAD
 Tests
Exercise stress test
Pharmacologic stress test
CT coronary angio
 Management
Life style changes +
Drugs :
1. Cardio protective
2. Antianginal
PCI
Surgery
 Cardioprotective medications: Reduce occurance of
cardiovascular events, reduce the progression of
systemic atherosclerosis and improve survival, include
1. Aspirin
2. Betablockers , target is to reduce HR to 60bpm
3. ACE I, especially in those have DM , HTN and
LVSD
4. Statins: It reduces death by 30% in IHD

Others: Selenium, B carotene, vitamin C and E, and

estrogen not improving survival and not recommended
 Antianginal medications:
Medications to reduce severity and frequency of angina, includes
1. Betablockers by reducing HR, contractility and BP resulting in reducing
oxygen demand
2. Nitrates reducing demand and improving oxygen supply, two categories of
nitrates are indicated, sublingual or spray for emergency cases and tropical or
oral for chronic use
nitrate use requires nitrate free period to avoid tolerance
3. CCB are second line to BB and Nitrate, in patient intolerant to BB
or have continue symptoms, all CCB cause systemic and coronary vasodilators
CCB are first line in prinzmetal angina
they are contraindicated in LVSD or advanced HB
4. Ranolazine, used if all above drugs failed and patient continue to have
symptoms