Sunday, November 3, 2013

Stable Angina

           Chronic Stable Angina is the initial manifestations of Ischemic Heart Disease in approximately half of patients with Coronary Artery Disease, Approxymately 15 millions American have CAD. Despite the well-documented decline in cardiovascular mortality, Ischemic Heart Disease remains the leading single cause of death in The United States and is reponsible for nearly one of every five deaths.


Definition of Stable Angina
        What is Angina? Angina is symptomof myocardial ischemia most commonly caused by coronary artery disease.
a. TYPICAL ANGINA (definite) is (1) Substernal chest discomfort with characteristic quality and 
    duration that is (2) precipitated by stress and (3) relieved by rest or nitroglycerin (NTG).
b. ATYPICAL ANGINA (probable) meets two of these criteria.
c. Noncardiac Chest Pain meets one or none of these criteria.

          Anginal equivalents vary from patient to patient but may include dyspnea on exertion, fatigue or weakness, diaphoresis, dizzines, nausea, or syncope. Women (more than men) may complain of epigastric discomfort thet otherwise presents like typical angina. Diabetic patients may experience anginal equivalent symtops (e.g, epigastric distress) that should be suspicious for underlying ischemia.


CLASSIFICATION 
            The Canadian Classification of Angina is commonly employed to stratify patients in terms of severity into the following groups:

I.    Angina only with strenous activity
II.   Moderate activity, such as walking more than one flight of stairs, yields angina.
III.  Mild activity, such as less than one flight of stairs, yield angina
IV.  Any activity, and even rest, yield angina.

            Keep in mind tha in the Canadian Classification, severity of angina is not directly related to the severity of angiographic stenosis. Higher-severity of angina correlates with increased short-term risk of death or nonfatal myocardial infarction.


PATHOPHYSIOLOGY
           Stable Angina most often results from fixed coronary lessions that produce a missmatch of myocardial oxygen supply and demand with increasing cardiac workload. Determinants of myocardial oxygen demand include heart rate, afterload or systemic vascular resistance, myocardial wall stress (measured by preload), and myocardial contractility. A fixed stenosis of an epicardial coronary artery, usually > 70% of the original luminal diameter of the vessel, is sufficient to limit blood flow distal to the lession. When myocardial workload (oxygen demand) exceeds the capacity of myocardial blood supply (oxygen delivery), angina may ensue. The presence of Ischemic Heart Disease can predispose patients to additional problems, including heart failure, cardiac arrythmias, and sudden cardiac death.

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