1. Hypoxia (including andoxia)
2. Insufficiency of metabolic substrates
3. Accumulation of metabolic waste

• When treated with nitroglycerin, MI chest pain does not go away immediately
• However, with angina, chest pain goes away immediately

• Ejection Fraction (EF)
• Left Ventricular Hypertrophy
• Valve malformation or dysfunction
• Other structural problems

Echo is also a low risk procedure

1. Male gender (2:1 men to women)
2. Cigarette smoking
3. High cholesterol levels (high LDL/low HDL)
4. High BP
5. Diabetes (impaired immune system)
6. Family history of coronary heart disease before age 55
7. Sedentary lifestyle
8. Obesity

1. Exercise
2. Eating
3. Emotional Stress
4. Sex
5. Cold temps

1. Younger patients
2. People with fewer coronary risk factors
3. Smokers

1. Coronary Artery Bypass Graft (CABG)
2. Percutaneous Transluminal Coronary Angioplasty (PTCA)
3. Direct Coronary Atherectomy (DCA): plaque is mechanically removed
4. Stens:

1. CABG more invasive than PCTA
2. CABG is higher risk than PCTA
3. CABG is longer lasting/More likely to have follow-up procedures with PCTA
4. CABG reduces symptoms better than PCTA
5. CABG is strongly preferred in diabetic patients/PCTA is not useful in diabetic patients
6. CABG may also be used to improve LV function
7. PCTA may be used in combination with stents and drug-stents
8. PCTA is best suited for new onset symptoms with large-artery stenosis

• NTG and nitrates
• CCB (non-DHP)

• Aspirin
• Clopidogrel
• Statins

• Beta-Blockers
• ACEI (?)

• Nitrate tolerance leads to loss of efficacy of drug
• Classic presentation of nitrate tolerance is it works for 2 weeks for the patient but then angina attacks start to reappear
• All patients must have an 8-12hr nitrate-free period to avoid tolerance

1. Patch: 12-14hrs per day off the patch
2. Dinitrate: if TID, it should be AC
3. Ointments: BID at most
4. IR Mononitrate: should be 7am, 3pm (or equivalent)
5. SR Mononitrate: Q24hrs

• Indicated for those with angina and either diabetes or LVH
• ACEI definitely make you live longer if you have diabetes or LVH
• May or may not improve mortality in those without these other conditions

1. Those with contraindications to Beta-Blockers (COPD, pulmonary disease)
2. Those with atrial arrhythmias (Non-DHP only)
3. Prinzmetal's Angina (DHP)
4. In combo with Beta-Blockers for additional benefit (monitor very closely)

• Cause arterial dilation (all) and reduces HR (Non-DHP)
• Can inhibit coronary vasospasm

• 1st agent in novel class: partial fatty-acid oxidation (PFox) inhibitors
• Will reduce myocardial oxygen demand by reducing metabolism
• Only indicated for those with stable angina who continue to have symptoms with standard therapy
• It is NOT a treatment for acute symptoms
• Do not take with grapefruit choice
• Potential for adverse effects associated with QT prolongation
• Less effective in women than in men

If LDL is between 100-129mg/dL:

modify their lifestyle, receive drug therapy, or both to achieve an LDL cholesterol level of <100mg/dL

If LDL is >130:

patient should receive drug therapy to reduce the level to less than 100mg/dL

• If you can get patient to 100 easily, you should try to get them down to 70
• If Framingham Score is above 10%, you should get them down to 70

• All patients with angina should receive aspirin unless absolutely contraindicated

Dose: 70-161mg/day

Contraindications:

1. acute liver disease
2. true aspirin allergy
3. aspirin trigger for pulmonary disease
4. recent GI bleed

• CCB (DHP and Non-DHP) are first line therapy
• Nitrates are useful to treat symptoms and as adjuncts to CCB as prophylaxis
• Combo of DHP and Non-DHP may be useful if solo agents fail
• Beta-blockers are not useful (may cause vasoconstriction of the arteries)

• Sex is a common trigger for  angina and MI
• PDE5-Inhibitors are safe in controlled angina but NEVER with a nitrate
• Exercise tolerance must be assessed in angina patients before PDE5 inhibitors are prescribed
• HR-limiting agents should be considered for sexually active angina patients
• Risk for acute MI should be discussed with men and women with angina