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TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI)

Dr. Zahoor

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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

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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

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

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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

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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)

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

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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

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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

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

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ANGINA PECTORISCalcium 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

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ANGINA PECTORISAspirin 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

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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

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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

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ANGINA PECTORISPCI 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

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ANGINA PECTORISCoronary 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

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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

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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

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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

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UNSTABLE ANGINA AND NSTEMITreatment 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

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UNSTABLE ANGINA AND NSTEMITreatment (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

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UNSTABLE ANGINA AND NSTEMITreatment (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

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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

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UNSTABLE ANGINA AND NSTEMIInvasive therapy PCI CABG Early invasive strategy is recommended

for patients - Recurrent ischemia at rest or minimal

exertion - Elevated cardiac enzyme – Troponin T

& I

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UNSTABLE ANGINA AND NSTEMIEarly invasive strategy is recommended

forPatients (cont) : - New ST segment depression - LVEF less than 40% - Hemodynamic instability e.g.

hypotension

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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

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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

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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

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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

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

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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

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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

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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

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

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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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Thank you