IT 1 .docx

**ischemic heart disease and Acute coronary syndrome.** **Introduction and epidemiology of ischemic heart disease and acute coronary syndromes** - Ischemic heart disease is not the same a s coronary artery disease. Meaning that IHD can be the result of ACS but not in all cases. - Angina p...

**ischemic heart disease and Acute coronary syndrome.** **Introduction and epidemiology of ischemic heart disease and acute coronary syndromes** - Ischemic heart disease is not the same a s coronary artery disease. Meaning that IHD can be the result of ACS but not in all cases. - Angina pectoris is a result of insufficient oxygen reaching the heart muscle and is a symptoms of IHD. **Ischemic heart disease (IHD): This is the big umbrella and ACS is an example** - **It is a condition where the heart is starved of oxygen due to reduced blood supply as a result of narrowed heart coronary arteries.** **Acute coronary syndrome (ACS):** - **It is related to sudden reduced blood flow to the heart muscle. When blood can not flow to the heart muscle, the heart muscle can become damaged.** - **This include Heart attack (which is Non-ST segment elevated myocardial infarction "NSTEMI" or ST-segment elevation myocardial infarction "STEMI. They both can cause the same symptoms but NSTEMI is less** damaging to the heart) and angina What is the prevalence of Coronary Heart Disease in Australia? - More than 2% of Australian live with CHD. - Men are twice likely than women to live with CHD. Has the rate of people with Coronary Heart Disease been increasing over time? - The rate of people with CHD has been decreasing over time. What proportion of deaths is Coronary Heart Disease responsible for? - One in ten of all deaths. How many Australians lose their life to Coronary Heart Disease each day? - One person loses their life every 30 minutes. - On average around 50 people every day. What proportion of men die from Coronary Heart Disease in comparison to women? - The proportion of men die from CHD is twice higher than women. How many people are hospitalised for Coronary Heart Disease each day? - Over 400 people are hospitalised for CHD every day. - 1 person every 3 to 4 minutes. **Introduction to coronary heart disease and Angina** - Coronary heart disease is where the coronary arteries are narrowed and reduce blood flow to the heart. - This can result in angina " is a symptoms and disease by it self", increasing the risk of myocardial infarction. **What is the difference between acute and stable angina?** - **Stable Angina (angina pectoris)** - is a retrosternal chest discomfort. "Pain or tightness" that last for 10 minutes or less and subsidised promptly with rest. - It occurs when myocardial oxygen demand exceeds supply, which can be restricted by atherosclerotic obstruction. - **Angina triggered by:** physical activity or emotional stress, cold temperature and eating a large meal. - **Angina risk factors:** a diet high in cholesterol and saturated fat, hypertension, cigarette smoking, insufficient physical activity, obesity, unmanaged diabetes, genetic factors or an inherited susceptibility. - **Angina symptoms:** Pain or discomfort of the chest, neck, back, arms or hands. Trouble breathing. tight, gripping or squeezing, centre of patient's chest. - **Epidemiology:** - Affect 3.36% of Australians - More common in Men (4.75%) than women (2.04%). - Higher prevalence in older populations. - 55-64 years: 2% - 65-74 years: 4.6% - 75-84 years: 7.8% - 85+: 14.5% - **Angina Diagnosis:** - Exercise stress test. - ECG while you ride stationary bicycle or walk on treadmill. - Cardiac catheterization. - Angiography - **Prinzmetal angina (coronary artery spam):** - Spasm of the coronary artery. Causing a chest pain. - Affected younger populations (\< 50 years). - Not participated by exertion or exercise. So it is non-exertional "occurs at rest" - Rare 2 out of 100 angina cases. - **Risk factors:** Smoking, female, some medicines (vasoconstrictors anti-migraine, cocaine and amphetamines), family history of CHD, Type A personality and alcohol **What is the recommended management for patients with angina presenting with acute chest pain?** 1. Immediately stop and rest to reduce the load on the heart. 2. If rest alone does not relieve the symptoms, advise patients to take a dose of their angina medicine. 3. If angina is not relieved, advise patients to take another dose of angina medicine. 4. Call (000) if the angina is not completely better within 10 minutes OR is severe or gets worse quickly. **What is the recommended pharmacological management for patients with stable angina?** - **Angina pectoris:** - **Aspirin:** used as primary prevention so they not going to have a myocardial infarction or stroke. - **Nitrate:** act as vasodilator so they help keep the blood flowing around the heart. - **Medication to lower the cholesterol level in the blood.** - **Medications to lower blood pressure and slow the heart rate.** - **Lifestyle changes: including quite smoking, losing excess body fat, switching to a low fat diet and do regular physical activity.** - **Surgery: angioplasty and coronary artery bypass.** - **Prinzmetal angina:** - Vasodilators. **What actions should be taken to prevent cardiovascular events by ensuring optimal management of underlying coronary artery disease and modifiable risk factors?** - **Beta blockers:** - **To prevent in people who do not have a ventricular dysfunction→ Beta blockers are the first line therapy to prevent episodes of angina. As it reduces the incidence of recurrent myocardial infarction. The type of beta used are Atenolol 25 mg once daily and Metoprolol 25 mg twice daily. Those can be increased to 100 mg daily.** - **To prevent in people who have a left ventricular dysfunction (ejection 40% or less)\--\> the recommended beta blockers for heart failure are Carvedilol, Bisoprolol, Nebivolol or metoprolol succinate.** - **Non-dihydropyridine calcium channel blocker** - Avoid using these two in patients with left ventricular dysfunction→ Verapamil and diltiazem reduces the heart rate and can be used if beta blockers are not tolerated or contraindicated and the patient does not have heart failure. Diltiazem MR 180 mg once daily and can be increased to 360 mg, Verapamil MR 120 mg once daily and can be increased to 480 mg. - **Dihydropyridine calcium channel blocker** - Amlodipine 2.5 mg once daily and can be increased up to 10 mg. Nifedipine MR 30 mg once daily and can be increased up to 90 mg. - If Angina persists one of the two above are added to beta blockers or can be used alone. - **Nitrate** - A **short-acting preparation of glyceryl trinitrate** can be taken before an activity that is likely to provoke angina. - A **long-acting nitrate preparation (transdermal glyceryl trinitrate, modified-release isosorbide mononitrate)** can be added either to a beta blocker, or to a nondihydropyridine calcium channel blocker (diltiazem, verapamil). - Long-acting nitrates (vasodilator) acts to prevent chest pain by improving coronary blood flow. It does not improve survival in patients with coronary artery disease. - If adding a nitrate to beta blocker, diltiazem or verapamil therapy to prevent angina use: - Glyceryl trinitrate 5 mg transdermally once daily, increase up to 20 mg once daily. - Isosorbide mononitrate MR 30 mg once daily, increase up to 120 mg daily. - What is a nitrate free intervals and why is it important? - Continuous therapy with nitrates rapidly produces tolerance along with loss or reduction of circulatory, antianginal and anti-ischemic effects. By allowing nitrate free intervals medication effectiveness is preserved. **Introduction to Acute coronary Syndromes (ACS)** - ACS are a broad spectrum of clinical presentations including all types of myocardial infarction or acute angina. - New/ increased symptoms are classified as having an acute coronary syndrome, while chronic symptoms are classified as having stable angina. It is important to note the new/ accelerated symptoms as it indicates the need for assessment and treatment. - Unstable angina (UA) occurs when blood supply is interrupted without cell death - Myocardial infarction (MI) occurs when the blood supply to the heart muscle is interrupted due to partial or complete occlusion of the coronary artery. As a result some of the heart muscle becomes infarcted "dies". - UA= cell damage but not death while MI = cell death - ACS resulted from unstable atherosclerotic plaques or endothelial disruption. With associated transient or permanent thrombotic occlusion of the coronary arteries. This leads to myocardial ischaemia and infarction. - Stable angina is usually due to a relatively fixed coronary obstruction produced by stable atherosclerotic plaque. **What are the signs and symptoms of ACS presentation?** - Chest discomfort "tightness, pressure, heaviness" at rest or for a prolong period "\>10 minutes, not relieved by sublingual nitrates". The pain that spreads to the neck, back arms, jaw or hands, shortness of breath, breath, sweating, dizziness or vomiting. - Recurrent chest discomfort. - Discomfort associated with acute heart failure. The pain may spread to other parts of the upper body: back, neck, arms, jaw, shoulders, epigastric pain. - The person may also experience Dyspnoea "shortness of breath" diaphoresis, dizziness or vomiting. **What are possible differential diagnoses APART from ACS:** - Other causes of acute chest pain include anxiety, GORD, PE and pneumonia. **What are the ACS diagnosis?** - ECG. - Troponin level "cardiac biomarkers which indicates damage to the myocardium"  **How do we treat patients exhibiting symptoms of an acute coronary syndrome?** - Urgently refer to hospital for reperfusion, patients are given aspirin, nitrates, pain relief and beta-blockers where required. **What are the management of ACS?** - Early response: treatment is critical - Time from symptoms onset and likely outcome. According to the below treatment time the damage will be - \ 12 hours: implement reperfusion strategy for patients presenting within 12 hours of onset of ischemic symptoms consistent with ACS. - We do ECG. - We give pain relief. - We do blood test for the cardiac biomarker - We give aspirin 150-300 mg immediately. - Then we give short acting nitrate or beta blocker to relieve the pain **Acute management: preparing for Reperfusion:** - Heparin to prevent clot maturation. - Antiplatelet therapy with either: - Clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75 mg/day) OR - Prasugrel (60 mg oral bolus + 10 mg daily) OR - Ticagrelor (180 mg oral bolus + 90 mg twice daily) - Careful assessment of bleeding risk. When we want reperfuse patient we need to consider the factors that increase the risk of bleeding: - Age \> 75 years - Female - History of bleeding - History of stroke or transient ischemic attack "TIA" - Creatinine clearance \< 60 ml/min - Diabetes - Heart failure. - Blood pressure \ - **Clopidogrel in preference to prasugrel** - **Fondaparinux in preference to enoxaparin.** - **Bivalirudin in preference to enoxaparin.** - For patient with low risk of bleeding we use the standard antiplatelet regimen. Examples are Grade A - **Prasugrel** - **Ticagerol** - Glycoprotein IIb/IIIa inhibitors are useful for patient who are having percutaneous intervention and there is no significant intervention for low risk patients "have more benefit with aspirin and heparin" - Abciximab "Reopro", Eptifibatide "integrilin", Tirofiban "aggrestat". - Inhibitors of platelet aggregation. - Act at glucoprotein IIb/IIIa receptor. **The choice of reperfusion therapy:** - This decision Is based on time. - If a patient can get into a facility that can perform primary angioplasty within 90 mins of their symptoms, then that is the treatment of choice. - If they can not get it within the time frame, then we should be looking at fibrinolysis. - In case of major delay to hospitalisation "\30 minutes" consider prehospital fibrinolysis. **Pharmacological management of Acute Coronary Syndromes** \- Patients with acute coronary syndrome usually present with acute chest discomfort or chest pain--equivalent symptoms such as shortness of breath, epigastric pain and left arm pain, though presenting symptoms can vary widely. \- Based on the electrocardiogram (ECG), patients are divided into either ST elevation myocardial infarction (STEMI) or non--ST elevation acute coronary syndromes (NSTEACS) (no persistent ST elevation on ECG). \- Based on cardiac troponin values, NSTEACS is further divided into non--ST elevation myocardial infarction (NSTEMI) (which presents with elevated troponin) and unstable angina. \- NSTEMI and unstable angina can progress to a STEMI, so ongoing monitoring is essential. \- The priority for managing **STEMI** is re-establishing blood flow in the occluded coronary artery (reperfusion), which is achieved with percutaneous coronary intervention (PCI), or thrombolytic therapy if PCI is unavailable. \- The priority for managing **NSTEMI** is plaque stabilisation, and the prevention of coronary occlusion with medical therapy (including antiplatelet and anticoagulant therapy) and revascularisation (ie stenting or bypass surgery). \- Thrombolytic therapy is **not** used to treat NSTEMI. **Initial assessment of chest pain**  **Acute reperfusion and invasive management** **Pharmacology for ACS** **\ ** **Discharge management**  **Assessment protocol for suspected ACS** **Pharmacology** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Drug | **Example | **MOA** | **Indicat | **Monitor | **Counsel | | Class** | ** | | ion | ** | ling | | | | | + dose** | | point** | | | | | | **Adverse | | | | | | | effect, | | | | | | | Precautio | | | | | | | n | | | | | | | and | | | | | | | contraind | | | | | | | ication)* | | | | | | | * | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Nitrate | **Glycery | **Nitrate | **Prevent | **Contrai | - **Thi | | ** | l | is a | ion | ndication | s | | | trinitrat | vasodilat | of | :** | medic | | | e** | or | angina** | | ine | | | | that | | - **Hyp | may | | | **Isosorb 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| | | | | | sick | | | | | | | sinus | | | | | | | syndr | | | | | | | ome | | | | | | | witho | | | | | | | ut | | | | | | | a | | | | | | | pacem | | | | | | | aker.** | | | | | | | | | | | | | | - **Ver | | | | | | | y | | | | | | | low | | | | | | | blood | | | | | | | press | | | | | | | ure | | | | | | | or | | | | | | | uncon | | | | | | | trolled | | | | | | | heart | | | | | | | failu | | | | | | | re.** | | | | | | | | | | | | | | **Precaut | | | | | | | ion:** | | | | | | | | | | | | | | **Dose | | | | | | | Adjustmen | | | | | | | t: | | | | | | | If kidney | | | | | | | function | | | | | | | gets | | | | | | | worse or | | | | | | | slow | | | | | | | heart | | | | | | | rate | | | | | | | (bradycar | | | | | | | dia) | | | | | | | happens, | | | | | | | the dose | | | | | | | of | | | | | | | beta-bloc | | | | | | | kers | | | | | | | might | | | | | | | need to | | | | | | | be | | | | | | | lowered.* | | | | | | | * | | | | | | | | | | | | | | **Shock: | | | | | | | Do not | | | | | | | use | | | | | | | beta-bloc | | | | | | | kers | | | | | | | if | | | | | | | someone | | | | | | | is in | | | | | | | shock | | | | | | | caused by | | | | | | | heart | | | | | | | problems | | | | | | | (cardioge | | | | | | | nic) | | | | | | | or low | | | | | | | blood | | | | | | | volume | | | | | | | (hypovole | | | | | | | mic).** | | | | | | | | | | | | | | **Hyperth | | | | | | | yroidism: | | | | | | | Beta-bloc | | | | | | | kers | | | | | | | can hide | | | | | | | symptoms | | | | | | | like fast | | | | | | | heartbeat | | | | | | | (tachycar | | | | | | | dia).** | | | | | | | | | | | | | | **Pheochr | | | | | | | omocytoma | | | | | | | : | | | | | | | Beta-bloc | | | | | | | kers | | | | | | | can make | | | | | | | high | | | | | | | blood | | | | | | | pressure | | | | | | | worse; | | | | | | | use an | | | | | | | alpha-blo | | | | | | | cker | | | | | | | first.** | | | | | | | | | | | | | | **Anaphyl | | | | | | | actic | | | | | | | Reactions | | | | | | | : | | | | | | | Beta-bloc | | | | | | | kers | | | | | | | can make | | | | | | | adrenalin | | | | | | | e | | | | | | | (epinephr | | | | | | | ine) | | | | | | | less | | | | | | | effective | | | | | | | for | | | | | | | severe | | | | | | | allergic | | | | | | | reactions | | | | | | |.** | | | | | | | | | | | | | | **Myasthe | | | | | | | nia | | | | | | | Gravis: | | | | | | | Symptoms | | | | | | | might get | | | | | | | worse | | | | | | | with | | | | | | | beta-bloc | | | | | | | kers.** | | | | | | | | | | | | | | **Hypogly | | | | | | | cemia: | | | | | | | Beta-bloc | | | | | | | kers | | | | | | | can hide | | | | | | | signs of | | | | | | | low blood | | | | | | | sugar, | | | | | | | such as a | | | | | | | fast | | | | | | | heartbeat | | | | | | | or | | | | | | | tremors.* | | | | | | | * | | | | | | | | | | | | | | **Preferr | | | | | | | ed | | | | | | | Types: | | | | | | | Beta1-sel | | | | | | | ective | | | | | | | beta-bloc | | | | | | | kers | | | | | | | (like | | | | | | | metoprolo | | | | | | | l) | | | | | | | and those | | | | | | | with | | | | | | | alpha1-bl | | | | | | | ocking | | | | | | | activity | | | | | | | (like | | | | | | | carvedilo | | | | | | | l) | | | | | | | are safer | | | | | | | for | | | | | | | people | | | | | | | with type | | | | | | | 2 | | | | | | | diabetes. | | | | | | | ** | | | | | | | | | | | | | | **Liver | | | | | | | Function: | | | | | | | Adjust | | | | | | | doses | | | | | | | carefully | | | | | | | based on | | | | | | | response | | | | | | | and side | | | | | | | effects, | | | | | | | except | | | | | | | atenolol, | | | | | | | which is | | | | | | | mainly | | | | | | | removed | | | | | | | by the | | | | | | | kidneys.* | | | | | | | * | | | | | | | | | | | | | | **Surgery | | | | | | | : | | | | | | | Keep | | | | | | | taking | | | | | | | beta-bloc | | | | | | | kers | | | | | | | before | | | | | | | and | | | | | | | during | | | | | | | surgery, | | | | | | | but watch | | | | | | | for slow | | | | | | | heart | | | | | | | rate and | | | | | | | low blood | | | | | | | pressure. | | | | | | | ** | | | | | | | | | | | | | | **Elderly | | | | | | | : | | | | | | | Start | | | | | | | treatment | | | | | | | with a | | | | | | | lower | | | | | | | dose.** | | | | | | | | | | | | | | **Pregnan | | | | | | | cy: | | | | | | | Avoid | | | | | | | atenolol | | | | | | | early in | | | | | | | pregnancy | | | | | | | and use | | | | | | | it | | | | | | | carefully | | | | | | | later | | | | | | | because | | | | | | | it might | | | | | | | affect | | | | | | | the | | | | | | | baby\'s | | | | | | | growth. | | | | | | | Beta-bloc | | | | | | | kers | | | | | | | can cause | | | | | | | slow | | | | | | | heart | | | | | | | rate in | | | | | | | the baby | | | | | | | and | | | | | | | newborn.* | | | | | | | * | | | | | | | | | | | | | | **Adverse | | | | | | | reaction: | | | | | | | ** | | | | | | | | | | | | | | **Common: | | | | | | | ** | | | | | | | | | | | | | | **Bradyca | | | | | | | rdia: | | | | | | | A slower | | | | | | | than | | | | | | | normal | | | | | | | heart | | | | | | | rate, | | | | | | | which | | | | | | | might | | | | | | | cause | | | | | | | dizziness | | | | | | | or | | | | | | | fatigue.* | | | | | | | * | | | | | | | | | | | | | | **Hypoten | | | | | | | sion: | | | | | | | Low blood | | | | | | | pressure, | | | | | | | which can | | | | | | | lead to | | | | | | | feelings | | | | | | | of | | | | | | | lighthead | | | | | | | edness | | | | | | | or | | | | | | | fainting. | | | | | | | ** | | | | | | | | | | | | | | **Orthost | | | | | | | atic | | | | | | | Hypotensi | | | | | | | on: | | | | | | | A sudden | | | | | | | drop in | | | | | | | blood | | | | | | | pressure | | | | | | | when | | | | | | | standing | | | | | | | up, | | | | | | | especiall | | | | | | | y | | | | | | | with | | | | | | | medicatio | | | | | | | ns | | | | | | | like | | | | | | | carvedilo | | | | | | | l | | | | | | | and | | | | | | | labetalol | | | | | | | , | | | | | | | leading | | | | | | | to | | | | | | | dizziness | | | | | | | or | | | | | | | fainting. | | | | | | | ** | | | | | | | | | | | | | | **Transie | | | | | | | nt | | | | | | | Worsening | | | | | | | of Heart | | | | | | | Failure: | | | | | | | Symptoms | | | | | | | may | | | | | | | temporari | | | | | | | ly | | | | | | | worsen | | | | | | | when | | | | | | | treatment | | | | | | | first | | | | | | | starts, | | | | | | | such as | | | | | | | increased | | | | | | | shortness | | | | | | | of breath | | | | | | | or | | | | | | | swelling. | | | | | | | ** | | | | | | | | | | | | | | **Nausea | | | | | | | and | | | | | | | Diarrhea* | | | | | | | * | | | | | | | | | | | | | | **Broncho | | | | | | | spasm | | | | | | | and | | | | | | | Dyspnea: | | | | | | | Tightenin | | | | | | | g | | | | | | | of the | | | | | | | airways | | | | | | | and | | | | | | | difficult | | | | | | | y | | | | | | | breathing | | | | | | | , | | | | | | | especiall | | | | | | | y | | | | | | | in people | | | | | | | with | | | | | | | asthma or | | | | | | | other | | | | | | | lung | | | | | | | condition | | | | | | | s.** | | | | | | | | | | | | | | **Cold | | | | | | | Extremiti | | | | | | | es: | | | | | | | Hands and | | | | | | | feet may | | | | | | | feel | | | | | | | unusually | | | | | | | cold due | | | | | | | to | | | | | | | reduced | | | | | | | blood | | | | | | | flow.** | | | | | | | | | | | | | | **Exacerb | | | | | | | ation | | | | | | | of | | | | | | | Raynaud's | | | | | | | Phenomeno | | | | | | | n: | | | | | | | Worsening | | | | | | | of | | | | | | | symptoms | | | | | | | in people | | | | | | | with | | | | | | | Raynaud's | | | | | | | , | | | | | | | such as | | | | | | | cold and | | | | | | | discolore | | | | | | | d | | | | | | | fingers | | | | | | | and | | | | | | | toes.** | | | | | | | | | | | | | | **Fatigue | | | | | | | , | | | | | | | Dizziness | | | | | | | , | | | | | | | Abnormal | | | | | | | Vision** | | | | | | | | | | | | | | **Alterat | | | | | | | ion | | | | | | | of | | | | | | | Glucose | | | | | | | and Lipid | | | | | | | Metabolis | | | | | | | m: | | | | | | | Changes | | | | | | | in blood | | | | | | | sugar and | | | | | | | cholester | | | | | | | ol | | | | | | | levels, | | | | | | | which can | | | | | | | affect | | | | | | | people | | | | | | | with | | | | | | | diabetes | | | | | | | or | | | | | | | cholester | | | | | | | ol | | | | | | | issues.** | | | | | | | | | | | | | | **Infrequ | | | | | | | ent/rare: | | | | | | | ** | | | | | | | | | | | | | | **halluci | | | | | | | nations, | | | | | | | insomnia, | | | | | | | nightmare | | | | | | | s, | | | | | | | heart | | | | | | | block, | | | | | | | rash, | | | | | | | alopecia, | | | | | | | exacerbat | | | | | | | ion | | | | | | | of | | | | | | | psoriasis | | | | | | | , | | | | | | | impotence | | | | | | | , | | | | | | | 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