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INTRODUCTION

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CASE STUDY

A 52-year-old man presents with a history of recent onset chest discomfort when jogging or swimming vigorously.* The pain is substernal and radiates to his jaw but disappears after 10–15 minutes of rest. He has a history of hyperlipidemia (total cholesterol level of 245 mg/dL and low-density lipoprotein [LDL] of 160 mg/dL one year ago) and admits that he has not been following the recommended diet. His father survived a “heart attack” at age 55 and an uncle died of some cardiac disease at age 60. On physical examination, the patient’s blood pressure is 145/90 mm Hg and his heart rate is 80 bpm. There are no other significant physical findings and an electrocardiogram is normal except for slight left ventricular hypertrophy. Assuming that a diagnosis of stable effort angina is correct, what medical treatment should be implemented?

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Ischemic heart disease is one of the most common cardiovascular diseases in developed countries, and angina pectoris is the most common condition involving tissue ischemia in which vasodilator drugs are used. The name angina pectoris denotes chest pain caused by accumulation of metabolites resulting from myocardial ischemia. The organic nitrates, eg, nitroglycerin, are the mainstay of therapy for the immediate relief of angina. Another group of vasodilators, the calcium channel blockers, is also important, especially for prophylaxis, and a blockers, which are not vasodilators, are also useful in prophylaxis. Several newer groups of drugs are under investigation, including drugs that alter myocardial metabolism and selective cardiac rate inhibitors.

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By far the most common cause of angina is atheromatous obstruction of the large coronary vessels (coronary artery disease, CAD). Inadequate blood flow in the presence of CAD results in effort angina, also known as classic angina. However, transient spasm of localized portions of these vessels, which is usually associated with underlying atheromas, can also cause significant myocardial ischemia and pain (vasospastic or variant angina). Variant angina is also called Prinzmetal angina.

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The primary cause of angina pectoris is an imbalance between the oxygen requirement of the heart and the oxygen supplied to it via the coronary vessels. In effort angina, the imbalance occurs when the myocardial oxygen requirement increases, especially during exercise, and coronary blood flow does not increase proportionately. The resulting ischemia usually leads to pain. In fact, coronary flow reserve is frequently impaired in such patients because of endothelial dysfunction, which is associated with impaired vasodilation. As a result, ischemia may occur at a lower level of myocardial oxygen demand. In some individuals, the ischemia is not always accompanied by pain, resulting in “silent” or “ambulatory” ischemia. In variant angina, oxygen delivery decreases as a result of reversible coronary vasospasm.

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Unstable angina, an acute coronary syndrome, is said to be present when episodes of angina occur at rest and when there is an increase in the severity, frequency, and duration of chest pain in patients with ...

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