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

2. 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

3. 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

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

5. 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

6. 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)

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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

31. 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

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

33. 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

34. 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

35. 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

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

37. 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

38. Thank you