TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI) Dr....
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Transcript of TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI) Dr....
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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 ANGINA
General 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 PECTORIS
Long 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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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
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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
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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 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
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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
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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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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