Angina exercise

Propranolol. Propranolol (Table 1), a Class II antiarrhythmic agent, is usefiil in the management of hypertrophic subaortic stenosis, especially for the treatment of exertional or other stress-induced angina by improving blood flow. The dmg can increase exercise tolerance in patients suffering from angina. Propranolol has been shown to have cardioprotective action in post-MI patients (37—39,98,99,108). 

Other P"Adrenoceptor Blocking Agents. Carteolol hydrochloride (Table 1) is also a Class II antiarrhythmic agent. In three separate studies in patients having angina pectoris, carteolol was considered effective as evidenced by a reduction in the frequency and severity of anginal episodes, reduction in the amount of nitroglycerin consumed, improvement of ECG parameters, or an increase in the duration of trea dmill exercise (42). 

Aggravation of cardiovascular disease (i.e., decreased exercise capacity in patients with angina pectoris, intermittent claudication, or peripheral arteriosclerosis)... 

Exercise facilitates both weight loss and blood pressure reduction. In addition, regular exercise improves functional capacity and symptoms in chronic stable angina.1 Once drug therapy for IHD is instituted, patients should be encouraged... 

Exercise tolerance (stress) testing (ETT) is recommended for patients with an intermediate probability of CAD. Results correlate well with the likelihood of progressing to angina, occurrence of acute MI, and cardiovascular death. Ischemic ST-segment depression during ETT is an independent risk factor for cardiovascular events and mortality. Thallium myocardial perfusion scintigraphy may be used in conjunction with ETT to detect reversible and irreversible defects in blood flow to the myocardium. 

Ranolazine is indicated for the treatment of chronic angina. Based on controlled trials, the improvement in exercise time is a modest increase of 15 to about 45 seconds compared with placebo. In a large ACS trial, ranolazine reduced recurrent ischemia but did not improve the primary efficacy composite end point of cardiovascular death, MI, or recurrent ischemia. 

Atherosclerosis in a coronary artery can lead to an infarct (see below). If the atherosclerosis is less severe, the reduction in the blood flow cannot provide enough oxygen in some conditions to support the work of the heart, for example during exercise or acute anxiety, and the resulting pain, angina pectoris, if frequent reduces the quality of life of the patient (Box 22.2). 

Q82 Exercise is contraindicated in controlled angina. Sv/imming is greatly associated with exercise-induced asthma. 

Exercise in not contraindicated in controlled angina. However, patients are advised to carry with them glyceryl trinitrate. Swimming is not associated with triggering of exercise-induced asthma. 

Acebutolol is effective in the management of the patient with essential hypertension, angina pectoris, and ventricular arrhythmias. Antiarrhythmic effects are observed with the patient both at rest and taking exercise. 

Because of these interindividual variations in the kinetics of propranolol, the therapeutic dose of this drug is best determined by titration. End points of titration include relief of anginal symptoms, increases in exercise tolerance, and plasma concentration of propranolol between 15 and 100 ng/mL. For additional details on the pharmacokinetics of propranolol and other (3-receptor antagonists approved for clinical use in the treatment of angina pectoris, see Table 17.3 and Chapter 11. 

By attenuating the cardiac response to exercise, propranolol and other (3-blockers increase the amount of exercise that can be performed before angina develops. Although propranolol does not change the point of imbalance between oxygen supply and demand at which angina occurs, it does slow the rate at which the imbalance point is reached. 

A 60-year-old man comes into the office complaining of chest pains that primarily occur in the early morning and do not appear to be associated with stress or exercise. Following coronary angiography and a positive ergonovine test you determine that this patient has angina pectoris as a result of coronary artery spasm. How would you (1) treat the patient to alleviate the acute attacks when they occur and (2) treat chronically to prevent their reoccurrence ... 

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