CHRONIC STABLE ANGINA Flashcards
What does the term ‘chronic stable angina’ refer to?
Angina that has been stable in frequency and severity for at least 2 months, provoked by exertion or stress of similar intensity.
What are the common causes of chronic stable angina?
Myocardial ischemia due to inadequate oxygen supply, usually caused by:
* Increased oxygen demands
* Narrowing or occlusion of coronary arteries.
What is ‘chronic coronary syndrome’?
A concept distinguishing between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS), similar to ‘stable ischemic heart disease’.
How is chronic stable angina classified?
Using the Canadian Cardiovascular Society system, graded on a scale of I to IV.
What are the grades of angina in the Canadian Cardiovascular Society classification?
Class I:
* No angina with ordinary activity
Class II:
* Slight limitation of ordinary activity
Class III:
* Marked limitations of ordinary activity
Class IV:
* Inability to engage in any physical activity without discomfort.
What laboratory tests should be conducted for a patient with newly diagnosed angina?
Tests should include:
* Creatinine
* Hemoglobin
* Hemoglobin A1c
* Fasting lipids
* 12-lead electrocardiogram (ECG).
What are the goals of treatment for chronic stable angina?
Goals include:
* Ameliorate angina
* Prevent major cardiovascular events
* Identify ‘high-risk’ patients for revascularization.
Which therapies improve symptoms in chronic stable angina?
Therapies include:
* Beta-blockers
* Nitrates
* Calcium channel blockers
* Ranolazine.
What is the first-line drug therapy for stable angina?
Beta-blockers, which decrease myocardial oxygen demands.
Are all beta-blockers equally effective for chronic stable angina?
Yes, they appear to have similar efficacy.
What is the proper dose of a beta-blocker?
Titrated to achieve a resting heart rate of 55 to 60 beats/minute.
When should a calcium channel blocker be used over a beta-blocker?
In patients with contraindications or intolerance to beta-blockers.
Should all chronic stable angina patients be prescribed sublingual nitroglycerin?
Yes, it is the standard of care.
When are long-acting nitrates prescribed?
Often prescribed with beta-blockers or nondihydropyridine calcium channel blockers.
When is ranolazine added to treatment?
For individuals with angina refractory to other antianginal medications.
What medications prevent MI or death in patients with stable chronic angina?
Medications include:
* Antiplatelet agents
* ACE inhibitors (in selected patients)
* Lipid-lowering therapy (statins)
* SGLT-2 inhibitors
* GLP-1 agonists.
What is the recommended dose of aspirin for chronic stable angina?
75 to 162 mg daily.
What is the alternative for patients with aspirin allergy?
Clopidogrel is a reasonable option.
When is dual antiplatelet therapy (DAPT) recommended?
In patients who have undergone coronary revascularization.
Should patients with chronic stable angina be treated with an ACE inhibitor?
Yes, for high-risk patients with specific conditions.
What is the LDL cholesterol goal for patients with chronic stable angina?
Patients should be started on a high-intensity statin to achieve a reduction of 50% or more.
What should be the duration of ACE inhibitor therapy in patients with left ventricular ejection fraction #40%?
ACE inhibitors should be started and continued indefinitely unless contraindicated
What is the recommended LDL cholesterol reduction for patients with clinical CVD according to the 2018 ACC/AHA guideline?
At least 50% LDL cholesterol reduction through high-intensity statin therapy
What should be added if LDL cholesterol is ≥70 mg/dL despite high-intensity statin therapy?
Ezetimibe may be added (Class IIb recommendation for low-risk patients and Class IIa for high-risk patients)
What is recommended for patients older than 75 years regarding statin therapy?
Initiation of moderate-intensity statin or continuation of high-intensity statin if tolerated (Class IIa recommendation)
What are the two purposes of stress testing in patients with chronic stable angina?
Diagnosis of CAD and prognosis in patients with presumed or known CAD
When is diagnostic stress testing appropriate?
For patients with an intermediate pretest probability of CAD
What is the pretest probability threshold below which diagnostic testing is not recommended?
Low (<10% pretest probability) or high (>90% pretest probability)
What is the average LDL cholesterol reduction for high-intensity statin therapy?
~50%
Name two high-intensity statins.
- Atorvastatin 40–80 mg
- Rosuvastatin 20–40 mg
Name two moderate-intensity statins.
- Atorvastatin 10–20 mg
- Simvastatin 20–40 mg
What findings on noninvasive testing would indicate referral for coronary angiography?
- High-risk findings
- Unprotected left main stenosis of at least 50%
- Large area of inducible ischemia
- Transient left ventricular ischemic dilation
- High-risk features on exercise ECG
- Drop in left ventricular ejection fraction
What are the indications for coronary revascularization in chronic stable angina?
- Symptoms interfering with lifestyle despite optimal medical therapy
- Coronary anatomic findings indicating survival benefit
What is the ABCDE approach for managing chronic stable angina?
- A: Aspirin and antianginal therapy
- B: Beta-blocker and blood pressure control
- C: Cigarette smoking and cholesterol
- D: Diet and diabetes
- E: Education and exercise
True or False: PCI is generally regarded as reducing the incidence of subsequent MI or cardiac death in patients with stable angina and preserved left ventricular ejection fraction.
False
What is the recommended treatment for patients with left main CAD?
Both CABG and PCI could be considered, but CABG has more durable benefits
What is the significance of the Fractional Flow Reserve (FFR) in revascularization decisions?
Identifies patients with functionally significant coronary stenosis who may benefit from revascularization
Fill in the blank: Patients with a history of acute coronary syndrome who have remained free of recurrent ACS for 1 year are considered to have transitioned to _______.
Stable Ischemic Heart Disease (SIHD)
What is the role of exercise testing in patients with high pretest probability of CAD?
A positive test confirms high clinical suspicion, while a negative result lowers the likelihood into the moderate range
