1 Dr. Zahoor Ali Shaikh
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CORONARY ARTERY DISEASE (CAD) CAD is most common form of heart disease and causes premature death. In UK, 1 in 3 men and 1 in 4 women die from coronary heart disease. Approximately 1.3 million people have angina every year. 3
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CORONARY ARTERY DISEASE Stable Angina It is due to transient myocardial ischemia and occurs when there is increased demand of oxygen by heart. 5
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7 CORONARY ARTERY DISEASE
STABLE ANGINA RISK FACTOR FOR STABLE ANGINA Hypertension Diabetes Mellitus Aortic valve disease - Angina is precipitated by - Anemia - Throtoxicosis 8
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INVESTIGATIONS ECG Exercise ECG – Exercise tolerance test (ETT). We monitor ECG, BP, and general condition of patient. 10
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12 INVESTIGATIONS Myocardial Perfusion Scan - Thallium stress test
INVESTIGATIONS Coronary Arteriography - Usually performed with a view to percutaneus coronary intervention (PCI) or coronary artery bypass graft (CABG) NOTE – PCI is done under local anesthesia in cardiac cath lab. - CABG surgery is done using left internal mammary artery or Saphenous vein. 13
14 INVESTIGATIONS
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16 MANAGEMENT OF ANGINA PECTORIS Assessment of patient Look for risk factors Advise to the patient
MANAGEMENT OF ANGINA PECTORIS Antiplatelet therapy – aspirin Antianginal drugs -Nitrate -Beta blocker -Calcium antagonist 17
ASPIRIN Inhibits platelet aggregation Inhibits synthesis of prostaglandin Thromboxone A2 and promotes reperfusion and reduces likelihood of thrombosis 18
NITRORGLYCERINE (NTG) Action It is venous and arteriolar dilator, therefore, decreases venous return and preload Decreases intraventricular volume and ventricular wall tension, therefore, decreases myocardial oxygen demand Sublingual NTG – peak action 4-8 minute, action last for minute Side effect - headache 19
BETA BLOCKER Beta blocker are very good for angina associated with effort Beta blocker decrease heart rate, blood pressure, and contractility of heart Therefore, decrease oxygen demand 20
CALCIUM CHANNEL BLOCKER Action Cause coronary dilatation and increase coronary flow Decrease myocardial contractility therefore decrease oxygen demand 21
CORONARY ARTERY SPASM It is called variant angina or Vasospastic or prinzmetal angina. Angina pain is due to spasm of coronary artery. ECG may show transient ST-elevation Treatment is with calcium blocker, nitrates. 22
ACUTE CORONARY SYNDROME (ACS) ACS is term used for 1. Unstable Angina 2. Myocardial infarction [MI] – NSTEMI 3. Myocardial infarction [MI] – STEMI Unstable Angina occurs at rest or minimal exertion in absence of myocardial damage. MI symptoms occur at rest and there is evidence of myocardial damage, demonstrated by increased level of cardiac Troponin or creatinine kinase-MB. IMPORTANT – Troponin is more specific 23
UNSTABLE ANGINA There is partial/intermittent occlusion of coronary artery Chest pain occurs at rest and lasts for more than 20 minutes ECG – ST depression, T wave changes (T inversion) Cardiac enzyme – Troponin T & I are normal Because No myocardial damage has occurred 24
NSTEMI Chest pain occurs at rest and lasts for more than 20 minutes ECG – ST depression, T wave changes (T inversion) Cardiac enzyme – Troponin T & I are increased Because myocardial damage has occurred 25
STEMI Severe Chest pain occurs at rest and lasts for 30 minutes to 1 hour ECG – ST elevation, T wave changes later Q wave appear Cardiac enzyme –Troponin T & I are increased and CK-MB increased 26
STEMI (cont) In STEMI, there is severe damage to the myocardium due to occlusion of blood flow in the coronary artery that causes death of myocardial tissue Sudden death from ventricular fibrillation or asystole within 1 hour can occur. 27
Patient with chest pain 28
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ACUTE CORONARY SYNDROME (ACS) Diagnosis Evaluation of ECG Measurement of biochemical markers of cardiac damage e.g. Troponin I and T, creatine kinase Cardiac Troponin T and I are most sensitive and specific marker of myocardial cell damage NOTE – Cardiac Biochemical markers are raised in MI. There is no rise in cardiac markers in angina. 31
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ACUTE CORONARY SYNDROME (ACS) Other blood test - WBC count - ESR - C-reactive protein - X-ray chest - Echo cardiography 33
MANAGEMENT Admit the patient Morphine IV for pain Aspirin Nitrate Beta-blocker Calcium channel blocker Reperfusion therapy Percutaneous Coronary Intervention (PCI) 34
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38 COMPLICATIONS OF ACUTE CORONARY SYNDROME
THANK YOU 39