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ANGINA ESTVEL
OBJECTIVO
OBJECTIVO
Aporte O2
- fluxo coronrio
- extraco/disponibilidade
(saturao, Hb, hematcrito) de O2
Necessidade O2
- frequncia
- contractilidade
- tenso intramiocrdica
(volume e presso ventricular)
Isqumia
miocrdica
OBJECTIVO TERAPUTICO
ALVIO (E PREVENO) DE EPISDIOS AGUDOS
PREVENO DE RECORRNCIAS
RISCO EM E SOBREVIDA (longo prazo)
Aterosclerose
HTA
TABAGISMO
DISLIPIDMIA
DM
OBESIDADE
SEDENTARISMO
IMP TRABALHO
Aporte O2
Necessidade O2
- fluxo coronrio
- extraco/disponibilidade
(saturao, Hb, hematcrito) de O2
- frequncia
- contractilidade
- tenso intramiocrdica
(volume e presso ventricular)
CASO PRTICO_1
JP, homem de 62 anos, jardineiro. Procura o seu mdico de famlia para avaliao de uma
dor no peito, que sinto h cerca de 3 semanas, ao levantar objectos pesados e ao caminhar,
especialmente em subidas. Refere que a dor cessa alguns minutos aps interrupo da
actividade e no surge em repouso. Refere ainda que no est associada s refeies ou a
situaes de stress emocional. At h 3 semanas atrs executava tarefas sem quaisquer
queixas.
A me e a irm morreram de ataque cardaco aos 62 e 57 anos de idade, respectivamente. O
pai, ainda vivo, com 86 anos de idade, sobreviveu a uma ataque cardaco e a um acidente
vascular cerebral. Ningum na famlia /foi diabtico.
JP no fumador e segue dieta de restrio salina. Porm, consome com regularidade a sua
refeio rpida preferida, 2 cheeseburguers e batatas fritas. obeso.
Outros problemas mdicos: HTA h 10 anos, DM h 4 anos, amputao traumtica da mo
direita.
Medicao crnica: atenolol 50 mg, losartan 50 mg, glipizida 5 mg 2 id.
CASO PRTICO_1
Na consulta no aparenta sinais de stress. PA na consulta 164/98 mmHg. Auscultao cardaca
e pulmonar e exame abdominal normais. Sem edemas perifricos.
ECG pedido revela ritmo sinusal, com todos os intervalos dentro dos limites normais e sem
evidncia de EM prvio. Perfil lipdico (LDL, HDL e TG) dentro de valores de referncia.
Estudo subsequente completo, que culmina em angiografia, permite identificar leses em 2
vasos coronrios (55 e 70%), sem envolvimento da descendente anterior lateral. Indicao
para teraputica farmacolgica do problema identificado: angina de peito estvel.
ESTVEL
FRMACOS
Dilatao
coronria
Contractilidade
++
NITRATOS
++
Vasodilatador,
NO
(mesmo na
presena de
aterosclerose)
BB
Frequncia
Ps-carga
Pr-carga
(resistncia arteriolar)
(retorno venoso)
++
++
++
++
++
++
bloqueio adrenrgico
BCC
bloqueio
canais Ca2+ (L)
circunstancialmente CONSIDERAR
NICORANDIL (NO + potssio)
IVABRADINA (bloqueio canais Na+/K+)
RANOLAZINA (bloqueio corrente tardia de Na+)
TRIMETAZIDINA (inibio da FOX; fatty acid oxidation)
NITRATOS
BB
DPOC
conduo AV
IC aguda
sndrome metablico
JP mantm-se a teraputica durante alguns meses, mas refere episdios de dor 1 a 4 vezes por
semana. Como anteriormente, as crises so precipitadas pela actividade fsica e aliviam aps
administrao sublingual de NTG.
PA controlada e FC normal.
O cardiologista decide prescrever um nitrato de longa durao de aco (dinitrato de
isossorbido 30 mg 3 id oral), bem como manter o BB.
QUESTES A DISCUTIR
- comentar prescrio de um BCC em vez de um nitrato
- principal cuidado com administrao crnica de um nitrato? como prevenir?
CASO PRTICO_2
CASO PRTICO_2
BB
ATENO
DPOC
conduo AV
IC aguda
sndrome metablico
IMPORTNCIA CARDIOSELECTIVIDADE
atenolol, metoprolol, bisoprolol, nebivolol, propranolol
(ex. obviar efeito broncoconstrictor mediado por 2)
CASO PRTICO_3
CASO PRTICO_3
ACC
DIHIDROPIRIDNICOS
amlodipina, nifedipina, lecarnidipina, felodipina
NO + com BB
resumindo
1) alvio (e preveno) de episdios agudos
NITRATOS aco rpida
IMP tempo de latncia, via/forma de administrao
2) profilaxia de recorrncias
BCC
1 linha
vascular disease.
Traditional anti-ischaemic drugs are the first step in medical treatment.52 Short-acting nitrates can be used to treat anginal attacks, but
Figure 4 summarizes the medical management of SCAD patients. This
common strategy might be adjusted according to patient comorbidoften they are only partially effective. b-Blockers seem a rational apities, contra-indications, personal preference and drug costs. The
proach because the dominant symptom is effort-related angina; they
medical management consists of a combination of at least a drug
were indeed found to improve symptoms in several studies and
Algoritmo
da
Sociedade
Europeia de
for angina relief plus drugs to improve prognosis, as well as use of
should constitute the first choice of therapy, particularly in patients
7.4 Strategy
Cardiologia
Angina relief
Event prevention
1st line
Short-acting Nitrates, plus
Beta-blockers or CCB-heart rate
Consider CCB-DHP if low heart rate or
intolerance/contraindications
Consider Beta-blockers + CCB-DHP if
CCS Angina > 2
Lifestyle management
Control of risk factors
May add or
switch (1st line
for some cases)
Aspirineb
Statins
Consider ACEI or ARBs
Ivabradine
Long-acting nitrates
Nicorandil
Ranolazinea
Trimetazidinea
2nd line
+ Consider Angio
PCI
Stenting or CABG
Figure 4 Medical management of patients with stable coronary artery disease. ACEI angiotensin converting enzyme inhibitor; CABG
coronary artery bypass graft; CCB calcium channel blockers; CCS Canadian Cardiovascular Society; DHP dihydropyridine; PCI
percutaneous coronary intervention.
a
Data for diabetics.
b
if intolerance, consider clopidogrel
ESC Guidelines
Class a
Level b
Ref. C
General
considerations
Task
Force
Members: Gilles Montalescot* (Chairperson) (France), Udo Sechtem*
I
C
Optimal medical treatment indicates at least one drug for angina/ischaemia relief plus drugs for event prevention.
(Chairperson) (Germany), Stephan Achenbach (Germany), Felicita
Andreotti
(Italy),
I
C
It is recommended to educate patients about the disease, risk factors and treatment strategy.
Chris Arden (UK), Andrzej Budaj (Poland), Raffaele Bugiardini (Italy), Filippo Crea
C
It is indicated
to review theCuisset
patients response
soon after startingCarlo
therapy. Di Mario (UK), J. RafaelI Ferreira
(Italy),
Thomas
(France),
(Portugal),
Angina/ischaemia relief
Bernard
J. Gersh (USA), Anselm K. Gitt (Germany), Jean-Sebastien Hulot (France),
I
B
Short-acting nitrates are recommended.
3, 329
Nikolaus Marx (Germany), Lionel H. Opie (South Africa), Matthias
Pfisterer
I
A
First-line treatment is indicated with -blockers and/or calcium channel blockers to control heart rate and symptoms.
3, 331
(Switzerland),
Eva Prescott (Denmark), Frank Ruschitzka (Switzerland),
Manel
Sabate
177, 307, 3,
(Spain), Roxy Senior (UK), David Paul Taggart (UK), Ernst E. van der Wall199, 284,
For second-line treatment it is recommended to add long-acting nitrates or ivabradine or nicorandil or ranolazine,
IIa
B
286, 308,
(Netherlands),
Christiaan
J.M. Vrints (Belgium).
according to heart rate, blood
pressure and tolerance.
319-321,
disease
d
328
ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach
IIb
B
For second-line
treatment,Baumgartner
trimetazidine may be(Germany),
considered.
313, 315 Dean
(Germany),
Helmut
Jeroen J. Bax (Netherlands), Hector Bueno
(Spain),
Veronica
(France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai
I
C
patients.
(Israel),
Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium),
Patrizio
Lancellotti
Linhart
(Czech
Republic),
Petros Nihoyannopoulos (UK),
Massimo
F. Piepoli
(Italy),
IIa
C
In asymptomatic
patients(Belgium),
with large areasAles
of ischaemia
(>10%)
-blockers
should be considered.
Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland),
In patients with vasospastic angina, calcium channel blockers and nitrates should be considered and beta-blockers
B
3, 365
Adam
Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). IIa
avoided.
It is recommended to use ACE inhibitors (or ARBs) if presence of other conditions (e.g. heart failure, hypertension or
diabetes).
348, 349,
351, 352
ACE
angiotensinauthors.
converting
SCADcontributed
stable coronary
* Corresponding
Theenzyme;
two chairmen
equallyartery
to the disease.
documents. Chairman, France: Professor Gilles Montalescot, Institut de Cardiologie, Pitie-Salpetriere University
a
Class
of recommendation.
Hospital,
Bureau
2-236,
47-83
Boulevard
de
lHopital,
75013
Paris,
France. Tel: +33 1 42 16 30 06, Fax: +33 1 42 16 29 31. Email: gilles.montalescot@psl.aphp.fr. Chairman, Germany:
b
Level
of evidence.
Professor
Udo Sechtem, Abteilung fur Kardiologie, Robert Bosch Krankenhaus, Auerbachstr. 110, DE-70376 Stuttgart, Germany. Tel: +49 711 8101 3456, Fax: +49 711 8101 3795, Email:
c
Reference(s)
supporting levels of evidence.
udo.sechtem@rbk.de
d
No demonstration of benefit on prognosis
Entities having participated in the development of this document:
ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention &
Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA)
Event prevention
Document
Reviewers: Juhani Knuuti (CPG Review Coordinator) (Finland), Marco Valgimigli (Review Coordinator)
333, 334,
(Italy),
He
ctor
(Spain), in
Marc
J. Claeys
I
ACetin Erol (Turkey),
Low-dose aspirinBueno
daily is recommended
all SCAD
patients. (Belgium), Norbert Donner-Banzhoff (Germany),
366
Herbert Frank (Austria), Christian Funck-Brentano (France), Oliver Gaemperli (Switzerland),
I
B
is indicated as an alternative
in caseMichalis
of aspirin intolerance.
335
JoseClopidogrel
R. Gonzalez-Juanatey
(Spain),
Hamilos (Greece), David Hasdai (Israel), Steen
Husted
(Denmark),
Stefan
K.
James
(Sweden),
Kari
Kervinen
(Finland),
Philippe
Kolh
(Belgium),
Steen
Dalby
Kristensen
(Denmark),
I
A
Statins are recommended in all SCAD patients.
62
Patrizio Lancellotti (Belgium), Aldo Pietro Maggioni (Italy), Massimo F. Piepoli (Italy), Axel R. Pries (Germany),
ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach
(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean
(France), Christi Deaton (UK), Cetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai
(Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium),
Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (Italy),
Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland),
Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland).
3
vegetables.
Document Reviewers: Juhani Knuuti (CPG Review Coordinator) (Finland), Marco Valgimigli (Review Coordinator)
(Italy), Hector Bueno (Spain), Marc J. Claeys (Belgium), Norbert Donner-Banzhoff (Germany), Cetin Erol (Turkey),
Herbert Frank (Austria), Christian Funck-Brentano (France), Oliver Gaemperli (Switzerland),
Jose R. Gonzalez-Juanatey (Spain), Michalis Hamilos (Greece), David Hasdai (Israel), Steen Husted (Denmark),
Stefan K. James (Sweden), Kari Kervinen (Finland), Philippe Kolh (Belgium), Steen Dalby Kristensen (Denmark),
Patrizio Lancellotti (Belgium), Aldo Pietro Maggioni (Italy), Massimo F. Piepoli (Italy), Axel R. Pries (Germany),
Hospital, Bureau 2-236, 47-83 Boulevard de lHopital, 75013 Paris, France. Tel: +33 1 42 16 30 06, Fax: +33 1 42 16 29 31. Email: gilles.montalescot@psl.aphp.fr. Chairman, Germany:
Professor Udo Sechtem, Abteilung fur Kardiologie, Robert Bosch Krankenhaus, Auerbachstr. 110, DE-70376 Stuttgart, Germany. Tel: +49 711 8101 3456, Fax: +49 711 8101 3795, Email:
udo.sechtem@rbk.de
Entities having participated in the development of this document:
ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention &
Rehabilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA)
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