Heart Failure and Angina Medication

Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure ( CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure) is a progressive syndrome characterized by the failure of the heart to maintain the metabolic demands of the body either due to systolic or diastolic dysfunction. Treatment of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure is centered around lifestyle modifications (salt and fluid restriction, smoking cessation, and weight loss) and pharmacologic management. Acute worsening of heart failure is often secondary to other medical conditions and is managed with aggressive diuresis and interventions to support cardiac and ventilatory functions. Angina is defined as chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain or discomfort resulting from myocardial ischemia. Therapy for angina is targeted at limiting platelet aggregation and adhesion (with antiplatelet agents Antiplatelet agents Antiplatelet agents are medications that inhibit platelet aggregation, a critical step in the formation of the initial platelet plug. Abnormal, or inappropriate, platelet aggregation is a key step in the pathophysiology of arterial ischemic events. The primary categories of antiplatelet agents include aspirin, ADP inhibitors, phosphodiesterase/adenosine uptake inhibitors, and glycoprotein IIb/IIIa inhibitors. Antiplatelet Agents), reducing O2 demand (with beta-blockers), reducing preload (with nitrates Nitrates Nitrates are a class of medications that cause systemic vasodilation (veins > arteries) by smooth muscle relaxation. Nitrates are primarily indicated for the treatment of angina, where preferential venodilation causes pooling of blood, decreased preload, and ultimately decreased myocardial O2 demand. Nitrates), and preventing the progression of atherosclerotic disease (using statin therapy), along with the management of comorbidities.

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Heart Failure

Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure ( CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure)

A clinical syndrome characterized by the inability of the cardiac output to meet the metabolic demands of the body:

  • Due to abnormal heart function and associated neurohormonal abnormalities
  • Leads to circulatory congestion and/or inadequate tissue perfusion
  • Results from the body’s attempt to compensate for heart failure

Decreased cardiac output activates the sympathetic nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System and RAAS:

  • Ensures brain and cardiac perfusion, but leads to the vicious cycle of chronic neurohormonal activation
  • ↑ Vasoconstriction → ↑ afterload → further ↓ in cardiac output
  • Renal perfusion → ↑ aldosterone → ↓ diuresis → ↑ overload
  • Catecholamines → promote arrhythmias and ↑ O2 consumption
  • Angiotensin II + norepinephrine → pathologic cardiac remodeling (hypertrophy, fibrosis, and cell death Cell death Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects. Cell Injury and Death)

Types:

  • Systolic heart failure:
    • Impaired myocyte contractility and dilated heart → reduced left ventricular (LV) ejection fraction and stroke volume
    • Also known as reduced ejection fraction heart failure (HFrEF)
  • Diastolic heart failure:
    • Inadequate relaxation and filling of the hypertrophied heart but normal myocyte contractility
    • Preserved ejection fraction despite low stroke volume
    • Also known as preserved ejection fraction heart failure (HFpEF)
  • Left-sided heart failure:
    • Most common form of heart failure
    • Fluid may build up in the lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs and cause dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea and pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema.
  • Right-sided heart failure:
    • Often occurs along with left-sided heart failure
    • Fluid builds up in the abdomen, legs, and feet, resulting in peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema.

Heart failure classification:

  • NYHA functional classification:
    • Class I: no limitations in physical activity
    • Class II: comfortable at rest but slight limitation during moderate/prolonged physical activity
    • Class III: comfortable only at rest. Daily activities, such as dressing up, result in marked limitations of physical activity.
    • Class IV: symptomatic even at rest
  • American Heart Association classification:
    • Stage A: high risk for heart failure but without structural heart disease, objective evidence of cardiovascular disease, or symptoms of heart failure
    • Stage B: structural heart disease/objective evidence of minimal cardiovascular disease but without signs or symptoms of heart failure
    • Stage C: structural heart disease/objective evidence of moderate-to-severe cardiovascular disease with prior or current symptoms of heart failure
    • Stage D: refractory heart failure/objective evidence of severe cardiovascular disease requiring specialized interventions

General therapy

Address the associated conditions or causes:

  • Ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease
  • Valvular heart disease
  • Cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Overview of Cardiomyopathies
  • Hypertension
  • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Arrhythmias (e.g., atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation)
  • Obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea
  • Hyperlipidemia
  • Others:
    • Advise smoking cessation.
    • ↓ Obesity and weight

Pharmacologic management depends on the type of heart failure:

  • HFrEF:
    • Diuretics
    • Beta-blockers (unless unstable in acute exacerbation of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure)
    • Renin-angiotensin system inhibitors (ACE inhibitor, ARB, or angiotensin receptor-neprilysin inhibitor (ARNi))
    • SGLT2 inhibitors (dapagliflozin)
    • Hydralazine + nitrate
    • Mineralocorticoid receptor antagonists (MRAs)
    • Digoxin
  • HFpEF:
    • The focus is on treating associated conditions, as a specific drug regimen has not been supported by trial data.
    • MRA for select individuals (needs monitoring)
    • Diuretics in case of volume overload (while carefully avoiding volume depletion)
    • ARBs, ACE inhibitors, calcium-channel blockers, and beta-blockers are used as indicated.
    • Avoid organic nitrates Nitrates Nitrates are a class of medications that cause systemic vasodilation (veins > arteries) by smooth muscle relaxation. Nitrates are primarily indicated for the treatment of angina, where preferential venodilation causes pooling of blood, decreased preload, and ultimately decreased myocardial O2 demand. Nitrates, digoxin, and phosphodiesterase (PDE) 5 inhibitors.

Pharmacologic Management of CHF

The medications used for the chronic management of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure (often HFrEF) to control and reduce symptoms, prevent progression, and for mortality benefit are listed below.

Table: Initial therapy to treat CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
Medication Mechanism of action Indication Mortality benefit
ACE inhibitors or ARBs Suppression of the renin-angiotensin system NYHA I–IV Yes
Angiotensin receptor-neprilysin inhibitors (valsartan-sacubitril) Sacubitril is a neprilysin inhibitor that decreases the breakdown of BNP. NYHA I–IV Yes
Beta-blockers Suppression of sympathetic tone (↓ catecholamine effects) NYHA I–IV Yes (specifically: metoprolol succinate, carvedilol, bisoprolol)
Thiazide or loop diuretics Loop diuretics Loop diuretics are a group of diuretic medications primarily used to treat fluid overload in edematous conditions such as heart failure and cirrhosis. Loop diuretics also treat hypertension, but not as a 1st-line agent. Loop Diuretics
  • Help lessen volume overload
  • ↓ Pulmonary edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • NYHA II–IV
  • Loop diuretics given in volume overload
Limited evidence

The following medications are used for the secondary therapy of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure:

Table: Secondary therapy of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
Medication Mechanism of action Indication Mortality benefit
Aldosterone antagonists Blockade of aldosterone at the receptor in the distal convoluted tubule
  • NYHA III–IV
  • Requires eGFR > 30 mL/min/1.73 m² and K+ < 5.0 mEq/dL
Yes
Digoxin
  • Blockade of Na+/K+ ATPase
  • ↑ Vagal tone
  • Results in a positive inotropic effect
May be particularly useful in individuals with atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation Reduces hospitalizations
Ivabradine
  • Blockade of funny (f channels) sodium currents in the sinoatrial node
  • Negative chronotropic effect (↓ HR)
  • NYHA II–III
  • Used particularly if individuals are not responsive to beta-blockers
  • HR must be ≥ 70/min (sinus rhythm).
Reduces hospitalizations
Hydralazine + isosorbide dinitrate
  • Hydralazine is a direct arteriolar vasodilator.
  • Nitrate therapy results in the peripheral dilation of veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins and arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries ( veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins > arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries).
  • Continued symptoms in Blacks with persistent symptoms despite therapy
  • Can be used as 1st-line treatment if ACE inhibitors, angiotensin receptor-neprilysin inhibitors, or ARBs are not tolerated
Yes
Dapagliflozin An SGLT2 inhibitor that promotes the renal excretion of glucose NYHA II–IV with or without DM DM Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus Yes
Vericiguat
  • Soluble guanylate cyclase stimulator
  • ↑ cGMP → ↑ smooth muscle relaxation and vasodilation
  • NYHA II–IV
  • An option if symptoms persist while on initial therapy and MRAs
Reduces hospitalizations
DM DM Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus: diabetes mellitus
MRA: mineralocorticoid receptor antagonist

Acute Exacerbation of CHF and Precautions in Pharmacotherapy

Acute decompensated CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure

  • Caused by several differential medical conditions such as:
    • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
    • Arrhythmias such as atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation
  • May be complicated by:
    • Severe pulmonary congestion 
    • Severe cardiogenic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
  • Most cases occur in the context of underlying chronic heart failure and are potentially fatal.
  • The goal of pharmacotherapy is to reduce volume overload, tailoring additional management to individual causes and comorbidities.

Medications

  • Diuretics:
    • IV administration of loop diuretics Loop diuretics Loop diuretics are a group of diuretic medications primarily used to treat fluid overload in edematous conditions such as heart failure and cirrhosis. Loop diuretics also treat hypertension, but not as a 1st-line agent. Loop Diuretics such as:
      • Furosemide
      • Torsemide
      • Bumetanide
    • Individuals on diuretic therapy for the treatment of chronic CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure will require higher doses of IV medications.
    • Due to different effects, the following parameters are monitored:
      • Renal function (may worsen)
      • Electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes (may be depleted)
      • Hemodynamic effects ( hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension can occur)
  • Vasodilator therapy may be required to reduce LV filling pressures and afterload:
    • Nitroprusside (causing arterial and venous dilation, decreasing both LV filling and systemic vascular resistance) is useful to treat:
      • Severe hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
      • Acute mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation
      • Acute aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
    • Nitrates:
      • Preload reduction, particularly if the individual is hypertensive
      • Reduces LV filling via venodilation
      • Contraindicated in individuals with hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension or those prescribed a phosphodiesterase inhibitor
  • Inotropic medications that may be used to manage cardiogenic shocks:
    • Dobutamine is a beta-1 adrenergic agonist.
    • Dopamine is a dopamine receptor agonist with beta-adrenergic effects at low doses and alpha-adrenergic effects at high doses.
    • Milrinone is a PDE3 inhibitor.
  • The use of beta-blockers in an acute setting depends on severity:
    • Hold medication in cases of severe decompensation.
    • Continue in cases of mild decompensation, if tolerated.

Use these drugs with caution in individuals with CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure

  • Calcium-channel blockers:
    • Especially drugs from the nondihydropyridine class
    • May cause an overall negative inotropic effect
  • Antiarrhythmics (class III agents such as sotalol, ibutilide, dofetilide):
    • Can produce a proarrhythmic effect
    • In heart failure, medications increase the risk for torsades de pointes.
  • Thiazolidinediones:
    • Can promote fluid retention
    • Can precipitate and worsen the progression of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
  • Metformin: associated with the risk of lactic acidosis
  • Some chemotherapeutic agents are cardiotoxic:
    • Anthracyclines
    • Cyclophosphamide
    • Trastuzumab
    • Bevacizumab
  • PDE5 inhibitors (sildenafil, vardenafil, tadalafil):
    • Vasodilators
    • ↑ Risk of hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension if used with nitrates Nitrates Nitrates are a class of medications that cause systemic vasodilation (veins > arteries) by smooth muscle relaxation. Nitrates are primarily indicated for the treatment of angina, where preferential venodilation causes pooling of blood, decreased preload, and ultimately decreased myocardial O2 demand. Nitrates

Angina

Angina pectoris:

  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or discomfort in the chest, often also spreading to the shoulders, arms, and neck/ jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint, which is caused by inadequate blood supply to the heart:
    • Description of pain: retrosternal location, dull/squeezing
    • Provoked by different factors: physical/emotional stress, meals, lying down, drugs
  • Stable angina is episodic chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain due to transient myocardial ischemia that results from coronary atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis.
  • Unstable angina is defined as the worsening of previously stable angina, or chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain at rest, or pain not relieved with nitroglycerin:
    • Manifests with ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) changes
    • Manifests without elevated troponin levels

Pharmacologic Management of Angina

Pharmacologic agents used initially

  • Antiplatelet therapy (aspirin)
  • Nitrates:
    • Sublingual nitroglycerin (0.4 mg every 5 minutes for a total of 3 doses)
    • Reduce myocardial O2 demand
    • Contraindications:
      • Recent use of a PDE5 inhibitor
      • Severe aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis
      • Hypertrophic cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is the most commonly inherited cardiomyopathy, which is characterized by an asymmetric increase in thickness (hypertrophy) of the left ventricular wall, diastolic dysfunction, and often left ventricular outflow tract obstruction. Hypertrophic Cardiomyopathy
      • Hypotension
      • Marked bradycardia
      • Suspected right ventricular infarct
  • IV morphine:
    • For severe, persistent chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
    • Effect: reduces sympathetic stimulation resulting from anxiety and pain
  • It is important to note that thrombolytic therapy is not administered to individuals with unstable angina or NSTEMI.

Further therapy

  • Beta-blockers
  • Statins Statins Statins are competitive inhibitors of HMG-CoA reductase in the liver. HMG-CoA reductase is the rate-limiting step in cholesterol synthesis. Inhibition results in lowered intrahepatocytic cholesterol formation, resulting in up-regulation of LDL receptors and, ultimately, lowering levels of serum LDL and triglycerides. Statins
  • Calcium-channel blockers:
    • Adjunctive therapy for individuals with recurrent symptoms
    • May be used in case of rapid atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation (when beta-blockers are contraindicated)
    • Do not use immediate-release nifedipine (causes reflex sympathetic activation/tachycardia).
  • Ranolazine:
    • To treat chronic stable angina
    • Mechanism: inhibits inward Na+ channels in ischemic cardiac muscles → ↓ calcium influx → ↓ ventricular tension and ↓ O2 demand

References

  1. Alaeddini, J., Shirani, J. (2018). Angina pectoris. Medscape. Retrieved June 13, 2021, from https://emedicine.medscape.com/article/150215-overview
  2. Chaudhary, I. (2020). Microvascular angina: Angina pectoris with normal coronary arteries. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/microvascular-angina-angina-pectoris-with-normal-coronary-arteries
  3. Colucci, W., Dunlay, S. (2021). Clinical Manifestations and diagnosis of advanced heart failure. In Mancini, S. (Ed.), UpToDate. Retrieved Dec 9, 2021, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-advanced-heart-failure
  4. Colucci, W. (2021). Overview of the management of heart failure with reduced ejection fraction in adults. In Gottlieb, S. (Ed.), UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/overview-of-the-management-of-heart-failure-with-reduced-ejection-fraction-in-adults
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  7. Mahler, S.A. (2021). Angina pectoris: Chest pain caused by fixed epicardial coronary artery obstruction. UpToDate. Retrieved June 20, 2021, from https://www.uptodate.com/contents/angina-pectoris-chest-pain-caused-by-fixed-epicardial-coronary-artery-obstruction
  8. Ponikowski, P., Voors, A., Anker, S., et al. (2016) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 37, 2129.
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  12. Sweis, R., Jivan, A. (2020). Unstable angina (acute coronary insufficiency; preinfarction angina; intermediate syndrome). MSD Manual Professional Version. Retrieved June 20, 2021, from https://www.msdmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/unstable-angina
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Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

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