Angina Ihd
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Transcript of Angina Ihd
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ISCHAEMIC HEART DISEASE
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Magnitude of the problem
USA 13.2 Million CAD , angina 6.8 million
CAD 54% of all CVD deaths(2001 US data)
Global deaths,CAD 7.1 to 11.1 million by2020
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A pain, vaguely described as:A heaviness
Pressure
Squeezing sensationConstriction
Aching burning pain
DiscomfortBreathlessness
Fauci et al. Harrison 1998; 1: 59-60.
Angina a typeof temporarychest painpressure ordiscomfort
Narrowedartery
IschemiaHeart muscle is not
receiving enoughoxygen due to anarrowed coronaryartery
DEFINITION
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Typical: Substernal region (center of the chest)Radiation:
Interscapular region(back of the chest)
ArmsShoulders
Teeth
AbdomenBack of neck
SITE
Braunwald et al. Harrison 1998; 1: 1365-80.
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Develops gradually during exertion
Appears after heavy meals
Associated with anger, excitement, frustration and otheremotional states
Resolves within 5-30 minutes
Braunwald et al. Harrison 1998; 1: 1365-80.
TYPICAL ANGINA
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CAD
Stable Angina
Unstable angina
Prinzmetal angina
Acute MI
Silent ischemia
Heart failure
arrhythmia
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STABLE ANGINA
Classification
Exertional
Anginal Equivalent Syndrome
Prinzmetals (Variant) Angina
Syndrome-X
Silent Ischemia
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ACS- clinical presentation
Ebers papyrus 2600BCIf you find a man with
heart discomfort,with pain in arms , at the
side of his heart,death is near
1. Occurring at rest lasting > 20 min
2. New onset severe angina < 1 month3. Crescendo angina
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Unstable angina -classification
Severity
Cl I New onset of severe/crescendo angina, no rest pain
Cl II Angina at rest within in one month but not < 48hrs
Cl III Angina at rest within 48 hrs
Clinical circumstances
A (secondary) extra cardiac condition
B (primary) absence of extra cardiac condition
C (post MI) within 2 weeks of MITIMI III registry , AJC 90:821,2002
Contd
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Unstable angina -classification
Intensity of treatment
1. In the absence of Rx for SAP
2. During Rx of SAP
3. Despite maximal medication for SAP
ECG Changes
With ECG changes
Without ECG changes
TIMI III registry , AJC 90:821,2002
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ACS-patho physiology
1. The development of unstable plaque
2. Acute ischemic event
3. Long term risk of recurrent coronary events
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Non occlusive thrombus
Thrombosis
Platelet activation & aggregation
Secondary haemostasis
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Angina-Dx tests
ECG
Chest X Ray
Resting echo
Exercise echo
Exercise ECG
Stress nuclear scan
Ambulatory ECG
CORONARY ANGIO
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RISK STRATIFICATION
History
Clinical class
ECG
Cardiac markers
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History
Advanced Age > 70 y
Diabetes mellitus
Post MI angina
Prior PAD
Prior CVA
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Angina - physical
Xanthelasma, HTN,PVD
LV dysfunction
Split S2
AS,HOCM, MVP Precipitating factors
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Clinical Presentation
Braunwald Cl II /III ( acute /sub acute)
Braunwald Cl B (sec)
Heart failure / hypotension
Ventricular arrhythmias
ECG changes
ST changes > 0.05 mV
T inversion
LBBB
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Cardiac markers
Increased TROP T /I ,CKMB
Increased CRP or WBC count
Increased BNP
Elevated CD40 ligand
Elevated glucose /HBA1 C Elevated s-creatinine
Angiogram
1. Thrombus
2. Triple vessel disease
3. Reduced LVEF
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Coronary Angio
TACTICS TIMI 18
34% TRIPLE VESSEL DISEASE
28% TWO VESSEL DISEASE
26% ONE VESSEL DISEASE
5-10% LMCD
13% NO CORONARY DISEASE
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Medical therapy
Anti thrombotic Rx
Anti ischemic Rx
Prevention of events
revascularization
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Anti thrombotic Rx
Aspirin
Clopidogrel,ticlopedine Heparin
Direct thrombin inhibitors
Anticoagulants Gp IIb /IIIa inhibitors
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Medical management
1. Identification &treatment of Ppt factors
2. Reduction of coronary risk factors
3. General methods-life style modification
4. Drugs
5. Revascularization- PCI , CABG
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Rx associated diseases
Anemia
Obesity
Occult thyrotoxicosis
Fever
Infection
anxiety
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Coronary risk factors
Hypertension
Smoking
Dyslipidemia
Diabetes
Inflammation- ACEI,Statins
Aspirin, clopidogrel
Beta blockers
Anti oxidents -no role
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Anti anginal drugs- Nitrates
Vasodilator action
Reduce ventricular preload, after load Redistribution of blood flow normal>ischemia
Anti thrombotic effect
Oral, sublingual, transdermal, IV
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Anti anginal drugs- Beta blockers
Anti ischemic, reduce oxygen demand Anti hypertensive
Anti arrhythmic
Reduce mortality in post MI
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Beta blocker
Ideal candidates
1. Physical activity
2. Coexistent HTN3. SVT, vent arrhythmias
4. Old MI
5. LVEF reduced6. Anxiety
Poor candidates
1. Asthma, COPD
2. Severe LVF
3. Severe Depression
4. Raynaud phenomenon
5. PVD
6. Severe bradycardia
7. Brittle diabetes
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Anti angina drugs- CCB
Reduce oxygen demand
Increase oxygen supply
Anti atherogenic
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Other therapies
Nicorndil-IONA study
Spinal cord stimulation
EECP
Chelation- no role
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PCI in angina
Medically refractory pts
Severe myocardial ischemia
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CABG- angina
Medically refractory Angina
LMCD, triple vessel disease
Diabetes with triple vessel disease
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