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TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI) Dr. Zahoor 1.

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Presentation on theme: "TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI) Dr. Zahoor 1."— Presentation transcript:

1 TREATMENT OF CHRONIC STABLE ANGINA AND ACUTE CORONARY SYNDROME (UNSTABLE ANGINA, NSTEMI, STEMI) Dr. Zahoor 1

2 CHRONIC STABLE ANGINA 2 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 3  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 4 General Treatment (Cont) v) Diet – Low saturated and transfats vi) Treat obesity vii) Treatment for anemia viii) Treat hyperthyroidisim

5 CHRONIC STABLE ANGINA 5 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 6 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 7 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 8  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 9 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 10 Contra indications  Chronic severe heart disease  AV block  Bronchial asthma

11 ANGINA PECTORIS 11 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 12 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 13  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 14  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 15 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 16 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] 17  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 18 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 19 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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21 UNSTABLE ANGINA AND NSTEMI 21 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 22 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 23 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 24 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 25 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 26 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 27 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) 28  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 29 Acute Transmural Anterior MI ECG is showing ST elevation in lead I, aVL, V 2, V 3, V 4, V 5, and V 6 There are Q waves in lead V 3 V 4 and V 5

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31 ST ELEVATION MYOCARDIAL INFARCTION (STEMI) 31 - 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 32 Initial therapy Goals are  Relief pain  Reperfusion therapy - PCI - Thrombolytic therapy  Prevent/treat arrhythmias

33 TREATMENT OUTLINE FOR STEMI 33  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 34  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 35  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 36  Heparin is given after thromlytic therapy  ACE inhibitors

37 COMPLICATION OF STEMI 37  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 38


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