9. angina.pptx

Coronary artery disease Iscaemic Heart Disease Coronary arteries coronary a. disease  Chronic coronary a. disease(ischaemic) stable silent variant ( Prinzmetal )  Acute coronary a. disease unstable NSTEMI STEMI Stable Angina Definition Generally described as retrosternal heavy or grip...

Coronary artery disease Iscaemic Heart Disease Coronary arteries coronary a. disease  Chronic coronary a. disease(ischaemic) stable silent variant ( Prinzmetal )  Acute coronary a. disease unstable NSTEMI STEMI Stable Angina Definition Generally described as retrosternal heavy or gripping sensation with radiation to left arm or neck, provoked by exertion and eased with rest or nitrates Stable angina pectoris Provoked by physical exertion, especially in cold weather, after meals and commonly aggravated by anger or excitement  The pain fades quickly with rest  In some patients pain occurs predictably at a certain level of exertion Etiology and pathogenesis Symptoms are results of myocardial ischemia due to insufficient blood flow through atherosclerotically changed coronary vessels Clinical symptoms Patient history is a˝golden standard˝ Retrosternal pain Dyspnea Nausea Restlessness Pain on exertion and relieved with rest or after taking nitrates History/Physical examination Risk factors Hypertension Diabetes Obesity Hyperlipidemia Smoking Excessive alcohol Family history Investigations Exercise ECG how the heart works while a person is exercising (walking o a treadmill or using an exercise bike). CT calcium scoring is a type of X‑ray that detects calcium in the coronary artery walls. Fat and calcium build up in the artery walls when a person has coronary heart disease and cause narrowing or blockages. Functional imaging tests show how the heart works under stress. Different tests can be used depending on the circumstances and the person's preferences. Invasive coronary angiography -any narrowed or blocked arteries. invasive CT coronary angiography computed tomography (CT) scanning and dye injected into the person's veins to show whether the coronary arteries are narrowed or blocked. Medical Treatment Symptomatic treatment: Aspirin, GTN, beta-blockers, statins long-acting nitrates, ACEI Percutaneous coronary intervention, coronary artery bypass grafting Acute coronary syndrome Chest pain • • • • • • Typical ACS History Chest pain or discomfort. center or left side of the chest that lasts for more than a few minutes or that goes away and comes back. Constricting Radiates to left arm and jaw/back Associated with sweating,nausea and vomiting The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain. Feeling weak, light-headed, or faint. You may also break out into a cold sweat. Shortness of breath Other DD of chest pain Aortic dissection/pericarditis Pleuritic/ GERD/ costochondritis Atypical Presentation ACS STEMI Non STEMI unstable angina Symptoms Chest pain Dyspnea Nausea and vomiting [esp. inferior wall MI] Anxiety Lightheadedness and syncope Cough Diaphoresis Fatigue syncope or weakness [ in elderly] physical examination Frequently,physical examination findings are normal Patients usually appear pale and diaphoretic and febrile [38 C] Hypotension indicates ventricular dysfunction due to ischemia Hypotension usually indicates a large infarct and may be observed with a right ventricular infarct ……. Acute valvular dysfunction may be present This dysfunction usually involves the papillary muscle Mitral regurgitation due to papillary muscle ischemia or necrosis may be present Congestive heart failure (CHF) may occur: Neck vein distention Third heart sound (S3) Rales on pulmonary examination New or worsening mitral regurgitant murmur may be noted A fourth heart sound is a common finding in patients with poor ventricular compliance that is due to a preexisting heart disease or hypertension. Dysrhythmias Diagnosis History and physical examination ECG [on an emergency basis] Serum cardiac biomarkers  CK MB [4-8HRS] and Total CK  Cardiac troponin T [ last for 7-10 days]  Myoglobin  AST  LDH  Others FSL/ RBS/ Renal function /CXR …….. ABCDE…….  Aspirin / clopidrogel  Anticoagulation  Nitrates  Beta blockers and blood pressure control  Cholesterol and cigarettes  Diet and diabetes control  Education and exercise Percutaneous coronary interventions (PCI; previously called angioplasty, percutaneous transluminal coronary, or balloon angioplasty) CABG ACUTE MI STEMI Management …… Total occlusion of the vessel for more than 4-6 hours results in irreversible myocardial necrosis, but reperfusion within this period can salvage the myocardium and reduce morbidity and mortality Treatment  Aspirin 325mg/clopidrogel  Low molecular weight heparin  High flow oxygen  Sublingual GTN  Morphine /Pethidine with antiemetics  Beta blockers /ACE inhibitors  Reperfusion : Thrombolytic drugs / PCI Thrombolytic drugs : As early as possible - restore coronary patency, - preserve ventricular function, - improve survival Infuse 1 500 000 IU streptokinase into a peripheral vein preferably over a short time of 1-2 hours PTCA : Safe & effective alternative to thrombolytic therapy / failed thrombolysis Contraindications ABSOLUTE :  Active bleeding, Active peptic ulcer, Active IBD, Active lung cavity disease, GI / Genitourinary bleeding < 6 months  Suspected Aortic dissection  Acute pericarditis  Recent major trauma, Prolonged CPR > 10 min, Surgical / invasive procedure < 10 days, Neurosurgical procedure < 2 months  Stroke / TIA < 12 months, H/O CNS tumor, aneurysm or AVM  Pregnancy RELATIVE:  SBP > 180 , DBP > 110 mm Hg  Bacterial endocarditis  Hemorrhagic diabetic retinopathy  H / O Intraocular bleeding  Stroke / TIA < 12 months  Brief CPR < 10 min  Chronic warfarin therapy  Severe renal / liver disease  Severe menstrual bleeding  Aspirin  ACEIs  Beta blockers  Tranquilisers  Stool softener  Diet – liquid / semisolid during the first 24- 48 hrs  Bed rest Complication Management Ventricular tachycardia:synchronized defibrillatorcardioversion Lidocaine Amiodarone beta-blockers Ventricular fibrillation: Defibrillation cpr Bradyarrhythmias : Atropine / pacemakers Recurrent ischemia : Nitrates beta-blockers morphine repeated reperfusion Congestive heart failure : Vasodilators IV inotropic agents diuretics (use with caution) IABP COMPLICATION TREATMENT Pericarditis : Nonsteroidal anti-inflammatory drugs Hypotension Volume replacement, inotropic agents, vasodilators, IABP, mechanical revascularization Papillary muscle rupture: Inotropic agents vasodilators IABP Ventricular septal rupture : Inotropic agents, vasodilators IABP mechanical revascularization Progression of AMI  Acute [first few hrs-7days]  Healing [7-28days]  Healed [>29days] Prognosis  50% deaths occur within 24 hours & about 40% of all affected pts die within the first month.  The early death is usually due to arrhythmia; later on the outcome is determined by extent of myocardial damage.  Poor LV function, heart blocks, BBBs, persistant ventricular arrhythmias, high enzyme levels, Anterior wall MI, old age,– higher mortality.  Of those who survive an acute attack, >80% live for 1 yr, about 75%- 5 yrs, 50%- 10 yrs, 25%- 20 yrs.   Thank you