TREATMENT of CHRONIC STABLE ANGINA AND acute coronary syndrome (unstable angina, nstemi, stemi) Dr. Zahoor

CHRONIC STABLE ANGINA Clinical presentation - Chronic Stable angina Chest pain ( Angina ) on exertion Pain lasts for 5-10 minute Cardiac enzyme – normal ECG – ST depression, T inversion maybe there

CHRONIC STABLE ANGINA Chronic Stable Angina Treatment 1- General Treat the risk factors i) Stop Smoking ii) Treatment of diabetes iii) Treatment of Hypertension iv) Treatment of lipid disorders

CHRONIC STABE ANGINA General Treatment (Cont) v) Diet – Low saturated and transfats vi) Treat obesity vii) Treatment for anemia viii) Treat hyperthyroidisim

CHRONIC STABLE ANGINA 2- Drug Therapy – Stable Angina i) Sublingual nitroglycerin – GTN 0.3 – 0.6mg maybe repeated at 5min interval Side effect – headache Prophylatic use of GTN GTN can be used prior to activity that evokes angina

CHRONIC STABLE ANGINA Important If chest pain persist more than 10 min despite 2-3 GTN, patient should report to the nearest medical facility for evaluation of possible unstable angina or acute myocardial infarction (MI)

ANGINA PECTORIS Long term treatment – Stable Angina Long acting nitrates Isosorbite dinitrate 5-30 mg TID orally Sustained action (slow release) 40mg Bid

CHRONIC STABLE ANGINA Skin patches of glycerol nitrate – 0.1 to 0.6 mg/hour Apply in the morning and remove at bedtime Side Effects of nitrate – headache, light headedness, tachycardia

ANGINA PECTORIS – Stable Angina Beta Blockers Beta I selective agent e.g. Tenormin , Bisoprolol Dose should be titrated to keep resting heart rate of 50-60 beats/min Side Effects – Bronchospasm, depressed left ventricular function, depression, masking hypoglycemia in diabetes mellitus

BETA BLOCKERS Contra indications Chronic severe heart disease AV block Bronchial asthma

ANGINA PECTORIS Calcium antagonist e.g. verapamil, diltiazem They are used for stableangina, unstable angina, and coronary vasospasm Combination of calcium antagonist with other anti angina is beneficial but verapamil should not be used with beta blocker as both have negative Inotropic effect

ANGINA PECTORIS Aspirin Aspirin 80 – 325mg/day It reduces the incidence of MI in chronic stable angina Contra indication - GI bleeding, Allergy Alternate (when patient can not tolerate aspirin) Clopidogrel (plavix) 75mg/day

ANGINA PECTORIS ACE inhibitors (angiotensin converting enzyme inhibitors) e.g. captopril, enalopril ACE inhibitors are indicated for patients with coronary artery disease when ejection fraction is less than 40%, hypertension, diabetes mellitus or chronic renal disease

ANGINA PECTORIS PCI – Percutaneous Coronary Intervention (Mechanical Revascularization) - Coronary angioplasty - Stenting PCI is more effective than medical therapy for relief of angina symptoms but does not reduce the risk of MI

ANGINA PECTORIS PCI With Coronary Angioplasty Chances of Restenosis is up to 30-45% within 6 months Stent – There are two types of intracoronary stent: i) Bare metal – Chances of restenosis 30% at 6 month ii) Drug eluting stent – restenosis usually not there, but late stent thrombosis can rarely occur Restenosis is prevented by prolonged anti platelet therapy – Aspirin life long, plavix (Clopidogrel) – 75mg/day for one year

ANGINA PECTORIS Coronary Artery bypass surgery (CABG) Indication In severe coronary artery disease (CAD) e.g. left main coronary artery or triple vessel disease (LAD, circumflex, right coronary artery) with left ventricle function impairment CABG is preferred over PCI in diabetes when there is coronary artery disease with triple vessel disease

ACUTE CORONARY SYNDROME [ACS] Unstable angina, NSTEMI and STEMI are called acute coronary syndrome Unstable angina and NSTEMI have similar mechanism, clinical presentation and treatment strategies We will discuss unstable angina and NSTEMI first, then treatment of STEMI

UNSTABLE ANGINA Clinical presentation - Unstable angina Chest pain at rest or minimal activity Pain lasts for more than 20mins Cardiac enzyme – normal ECG – ST depression, T inversion maybe there

NSTEMI Clinical Presentation of NSTEMI Chest pain at rest or minimal activity Pain lasts for more than 20mins Cardiac enzyme – Troponin – T & I increased ECG – ST depression and or T wave inversion (No ST elevation, No Q wave development) Note – Troponin T & I are more specific and sensitive markers of myocardial damage

UNSTABLE ANGINA AND NSTEMI Treatment Aspirin 81mg - 4 tablet stat – chewable then 81mg/day orally Plavix (Clopidogrel) 75mg – 4 tablet stat then 75mg/day Low molecular weight heparin – Enoxaprin 1mg/kg sc 12 hourly NOTE – Fibrinolytic therapy is not given to the patient with unstable angina/NSTEMI

UNSTABLE ANGINA AND NSTEMI Treatment (cont) Anti-ischemic therapy Nitro glycerin 0.3 - 0.6 mg sublingually, repeat 3 doses given five minute apart If chest discomfort persist then give IV nitro glycerin

UNSTABLE ANGINA AND NSTEMI Treatment (cont) --Beta blocker are given. If beta blockers are contra indicated e.g. Bronchospasm then give long acting calcium antagonist e.g. verapamil or diltiazem

UNSTABLE ANGINA AND NSTEMI Additional Recommendations Admit the patient to a unit with continuous ECG monitoring - CCU Bed rest If pain morphine sulphate 2-5 mg IV Atrovastatin (Lipitor) – lowers lipids – initially 80mg/day (it is HmG – Co A reductase inhibitor) ACE inhibitors

UNSTABLE ANGINA AND NSTEMI Invasive therapy PCI CABG Early invasive strategy is recommended for patients - Recurrent ischemia at rest or minimal exertion - Elevated cardiac enzyme – Troponin T & I

UNSTABLE ANGINA AND NSTEMI Early invasive strategy is recommended for Patients (cont) : - New ST segment depression - LVEF less than 40% - Hemodynamic instability e.g. hypotension

UNSTABLE ANGINA AND NSTEMI Long term management Stop smoking (if smoker) Optimal weight achievement Diet – low and saturated and transfats Regular exercise Drug treatment Aspirin – long term Plavix Beta blocker Statins ( Lipitor ) ACE inhibitors

We will discuss ST ELEVATION MYOCARDIAL INFARCTION (STEMI) Diagnosis of STEMI is based on - Pain – more severe and persistent, not fully relieved by GTN, often accompanied by nausea, sweating - ECG – ST elevation, followed by T inversion than Q wave development, over several hours

Acute Transmural Anterior MI ECG is showing ST elevation in lead I, aVL, V2, V3, V4, V5, and V6 There are Q waves in lead V3 V4 and V5

ST ELEVATION MYOCARDIAL INFARCTION (STEMI) - Cardiac biomarkers – Troponin T and I are increased, they are highly specific for myocardial injury. - CKMB Isoenzyme increased Echocardiography It shows infarct associated regional wall motion abnormalities

TREATMENT OUTLINE FOR STEMI Initial therapy Goals are Relief pain Reperfusion therapy - PCI - Thrombolytic therapy Prevent/treat arrhythmias

TREATMENT OUTLINE FOR STEMI Aspirin 81mg 4 tablet chewable then oral therapy Reperfusion therapy 1) PCI is done within 2 hours and is preferred as it is more effective (when facilities are available) If PCI not available, IV fibrinolysis 2) Fibrinolysis (tPA, streptokinase) gives most benefit when given with in 3 hours after MI, but can be used up to 12 hours

TREATMENT OUTLINE FOR STEMI Admit in CCU, continuous ECG monitoring IV line for emergency arrhythmia treatment Pain control – morphine sulphate 2-4mg IV slowly over 5-10mins If pain continues give I/V GTN Oxygen 2-4 liters/min by nasal cannula

TREATMENT OUTLINE FOR STEMI Soft diet Stole softener Beta Blocker – they reduce oxygen demand limit infarct size, reduce motility Contra indications of Beta Blockers - Systolic blood pressure less than 95mmHg - Heart rate less than 50/min - A : V block - History of Bronchospasm

TREATMENT OUTLINE FOR STEMI Heparin is given after thromlytic therapy ACE inhibitors

COMPLICATION OF STEMI Ventricular arrhythmias -- Ventricular Ectopic -- Ventricular tachycardia -- Ventricular fibrillation Supraventricular arrhythmias -- Atrial fibrillation -- Atrial flutter -- Paroxysmal supraventricular tachycardia AV Block -- Due to AV node ischemia

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