Holistic management of chest pain: Consensus Statement
Delhi: A consensus statement, devised with the help of multiple meetings held across India, published in the JAPI: Journal of the Association of Physicians of India, focuses on the holistic management of angina. The goals of anti-ischemia therapy in patients with stable coronary artery disease (CAD) include relieving angina symptoms, improving the duration of exercise and quality of life, improving prognosis, and preventing cardiovascular (CV) events.
Worldwide, ischemic heart disease is a major cause of morbidity and mortality. Moreover, angina pectoris is a frequent symptom manifestation. The goals of anti-ischemia therapy in patients with stable coronary artery disease (CAD) include relieving angina symptoms, improving the duration of exercise and quality of life, improving prognosis, and preventing cardiovascular (CV) events.
The following consensus statements on the definition, diagnosis, and management of angina reported in the article were developed based on the extensive literature review, intense discussions, and feedback from the cardiologists.
Expert group recommendation 1: Definition
- The terminology of stable angina/stable CAD has been replaced with chronic coronary syndromes (CCS).
- Coronary syndromes are categorized into CCS and acute coronary syndrome (ACS).
- ACS is further classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or unstable angina.
- CCS is further classified as:
- Stable angina
- New heart failure (HF) and suspected CAD
- Stabilized symptoms for less than a year post ACS or PCI
- Stabilized symptoms for more than a year post initial diagnosis
- Patients with angina and suspected microvascular disease
- Asymptomatic CAD detected at screening
Expert group recommendation 2: Diagnosis
- Microvascular angina and vasospastic angina are diagnosis of exclusion.
- If ischemia is present on resting electrocardiogram (ECG) and echocardiogram (ECHO) as ischemia is present on resting.
Expert group recommendation 3: Management
Heart Rate
- Pharmacotherapy
- Additional therapies
- Counselling, ACE inhibitors, anxiolytics, control of lipids and anemia are equally important in the management of CSA.
- Statins have shown to prevent secondary events as well as improve the chest pain in non-obstructive angina.
- Both aspirin and statins are indicted for microvascular dysfunction and show the most benefits.
- In certain individuals, anxiolytics have demonstrated to relieve chest pain
- Revascularization
- Angina management in special population
Angina in Hypotension and Bradycardia Patients
- Approximately 10% of patients develop hypotension and bradycardia, which leads to negative outcome
- Prescribing nitrates or beta blockers to elderly patients can lead to hypotension/bradycardia
- To manage hypotension, adjust the doses of the prescribed antianginal drugs and assess if there is deterioration of left ventricular function
- Trimetazidine and ranolazine can be prescribed as it does not alter the blood pressure.
Angina in Diabetes Patients
· Almost 50% of angina patients are diagnosed with diabetes.
· In patients with DM who have systolic heart failure, if angina persists after beta blockers or nitrates or calcium channel blockers, trimetazidine or ranolazine are preferred.
· Ranolazine is preferred in diabetes patients as it significantly reduces glycated haemoglobin levels.
· In patients with newly diagnosed diabetes, intense diabetes control decreases both micro as well as macrovascular complications.
Newer Therapies
· Preference should be given to newer emerging antianginal therapies especially trimetazidine
· Agents such as allopurinol, coronary sinus reducer, enhanced external counter pulsation, neuromodulation are being investigated for management of CSA.
Reference:
"Consensus Statement on Holistic Management of Angina," is published in the JAPI: Journal of the Association of Physicians of India.
DOI: https://japi.org/x294a454/consensus-statement-on-holistic-management-of-angina
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