Stable and Unstable Angina

Ali El Safadi

PBL 2: I have chest pain.

Cardiology Module
Academic Year 2017 - 2018
Outline
Introduction
Classification
Pathophysiology of angina
Management
Treatment
Correlation to the case
References
Introduction
Angina pectoris is the sensation of
chest pain
pressure
or squeezing sensation, often due to ischemia of the heart
muscle from obstruction or spasm of the coronary arteries.

While angina pectoris can derive from anemia, abnormal

heart rhythms and heart failure, its main cause is coronary
artery disease, an atherosclerotic process affecting
the arteries feeding the heart.
Introduction
There is a weak relationship between severity of pain and
degree of oxygen deprivation in the heart muscle
i.e., there can be severe pain with little or no risk of
a myocardial infarction and a heart attack can occur without
pain.
Worsening ("crescendo") angina attacks, sudden-onset
angina at rest, and angina lasting more than 15 minutes are
symptoms of unstable angina (usually grouped with similar
conditions as the acute coronary syndrome).
Classification
Stable angina
Unstable angina

Based on:
Symptoms
Pathophysiological processes
Stable Angina
Also known as effort angina,
Refers to the classic type of angina related to myocardial
ischemia.
A typical presentation of stable angina is:
Chest discomfort
Associated symptoms precipitated by some activity
Minimal or non-existent symptoms at rest or after
administration of sublingual nitroglycerin.
Stable Angina

Symptoms typically abate several minutes after activity and

recur when activity resumes.
In this way, stable angina may be thought of as being similar
to intermittent claudication symptoms.
Other recognized precipitants of stable angina include cold
weather, heavy meals, and emotional stress.
Unstable Angina
Unstable angina (UA) (also "crescendo angina"; this is a form
of acute coronary syndrome) is defined as angina pectoris
that changes or worsens.
It has at least one of these three features:
it occurs at rest (or with minimal exertion), usually lasting
35 minutes
it is severe and of new onset (i.e., within the prior 46
weeks)
it occurs with a crescendo pattern (i.e., distinctly more
severe, prolonged, or frequent than before).
 Unstable Angina

What differentiates stable angina from unstable angina (other than

symptoms)?

The pathophysiology of the atherosclerosis.

The pathophysiology of unstable angina is the reduction of coronary

flow
due to transient platelet aggregation on apparently normal
endothelium
coronary artery spasms
or coronary thrombosis.
Pathophysiology of Angina
The process starts with atherosclerosis,
progresses through inflammation
to yield an active unstable plaque
which undergoes thrombosis
and results in acute myocardial ischemia
which, if not reversed, results in cell necrosis
Pathophysiology of Angina

In stable angina, the developing atheroma is protected with

a fibrous cap.
This cap may rupture in unstable angina, allowing blood clots
to precipitate and further decrease the area of the coronary
vessel's lumen.
This explains why, in many cases, unstable angina develops
independently of activity
 Treatment
The most specific medicine to treat angina is nitroglycerin.
It is a potent vasodilator that makes more oxygen available to the heart muscle.

Beta blockers and calcium channel blockers act to decrease the heart's workload,
and thus its requirement for oxygen.

Treatments for angina are balloon angioplasty.

Stents to maintain the arterial widening are often used at the same time.
Coronary bypass surgery involves bypassing constricted arteries with venous
grafts.
 Treatment
The main goals of treatment in angina pectoris are
relief of symptoms
slowing progression of the disease
and reduction of future events, especially heart attacks and death.

Beta blockers have a large body of evidence in morbidity and

mortality benefits
and short-acting nitroglycerin medications have been used for
symptomatic relief of angina.
Calcium channel blockers, and isosorbide mononitrate are
vasodilators commonly used in chronic stable angina.
Low-dose aspirin decreases the risk of heart attack in patients with
chronic stable angina, and was part of standard treatment.
Treatment
Exercise is also a very good long-term treatment for the
angina
Identifying and treating risk factors for further coronary
heart disease is a priority in patients with angina
Testing for elevated cholesterol
Diabetes
Hypertension
Smoking cessation
Weight optimization
Correlation to the case
Case:
A 67-year-old retired man, hypertensive and heavy smoker, is
brought to the emergency room in an ambulance car 20
minutes after the onset of an acute left chest and upper
abdominal pain triggered by a heavy meal associated with pallor
and sweating.

PE: non remarkable (r/o)

Dx: Hypertensive dyslipidemic patient with a high CHD risk
presenting with symptoms of unstable angina
References
http://emedicine.medscape.com/article/159383-treatment
https://en.wikipedia.org/wiki/Angina_pectoris#Treatment
http://circ.ahajournals.org/content/108/16_suppl_1/III-
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