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

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 50-60 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 antagoniste.g. verapamil, diltiazem • They are used for stableangina, unstable angina, and coronary vasospasm • Combination of calcium antagonist with other anti angina is beneficial but verapamilshould 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 statthen 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 0.3 - 0.6 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