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TREATMENT OF CHRONIC STABLE ANGINA
AND ACUTE CORONARY SYNDROME
(UNSTABLE ANGINA, NSTEMI, STEMI)
Dr. Zahoor
CHRONIC STABLE ANGINA
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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
CHRONIC STABLE ANGINA
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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
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CHRONIC STABE ANGINA
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General Treatment (Cont)
v) Diet – Low saturated and transfats
vi) Treat obesity
vii) Treatment for anemia
viii) Treat hyperthyroidisim
CHRONIC STABLE ANGINA
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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
CHRONIC STABLE ANGINA
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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)
ANGINA PECTORIS
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Long term treatment – Stable Angina
Long acting nitrates
 Isosorbite dinitrate 5-30 mg TID orally
 Sustained action (slow release) 40mg Bid
CHRONIC STABLE ANGINA
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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
ANGINA PECTORIS – Stable Angina
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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
BETA BLOCKERS
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Contra indications
 Chronic severe heart disease
 AV block
 Bronchial asthma
ANGINA PECTORIS
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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
ANGINA PECTORIS
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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
ANGINA PECTORIS
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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
ANGINA PECTORIS
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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
ANGINA PECTORIS
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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
ANGINA PECTORIS
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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
ACUTE CORONARY SYNDROME [ACS]
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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
UNSTABLE ANGINA
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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
NSTEMI
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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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UNSTABLE ANGINA AND NSTEMI
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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
UNSTABLE ANGINA AND NSTEMI
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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
UNSTABLE ANGINA AND NSTEMI
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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
UNSTABLE ANGINA AND NSTEMI
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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
UNSTABLE ANGINA AND NSTEMI
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Invasive therapy
 PCI
 CABG
 Early invasive strategy is recommended for patients
- Recurrent ischemia at rest or minimal exertion
- Elevated cardiac enzyme – Troponin T & I
UNSTABLE ANGINA AND NSTEMI
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Early invasive strategy is recommended for
Patients (cont) :
- New ST segment depression
- LVEF less than 40%
- Hemodynamic instability e.g. hypotension
UNSTABLE ANGINA AND NSTEMI
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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
We will discuss
ST ELEVATION MYOCARDIAL INFARCTION (STEMI)
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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
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
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ST ELEVATION MYOCARDIAL
INFARCTION (STEMI)
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- 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
TREATMENT OUTLINE FOR STEMI
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Initial therapy
Goals are
 Relief pain
 Reperfusion therapy
- PCI
- Thrombolytic therapy
 Prevent/treat arrhythmias
TREATMENT OUTLINE FOR STEMI
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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
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TREATMENT OUTLINE FOR STEMI
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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
TREATMENT OUTLINE FOR STEMI
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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
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TREATMENT OUTLINE FOR STEMI
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Heparin is given after thromlytic therapy
ACE inhibitors
COMPLICATION OF STEMI
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Ventricular arrhythmias
-- Ventricular Ectopic
-- Ventricular tachycardia
-- Ventricular fibrillation
Supraventricular arrhythmias
-- Atrial fibrillation
-- Atrial flutter
-- Paroxysmal supraventricular tachycardia
AV Block
-- Due to AV node ischemia
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Thank you