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M of angina & ami

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  • 1. Management of Angina andAcute Myocardial Infarction
  • 2. CLINICAL PRESENTATIONS
  • 3. I. Stable angina pectoris Ischaemia due to fixed athromatousstenosis
  • 4. II. Unstable angina Dynamic obstruction due to plaque rupture and superimposed thrombosis
  • 5. III. Acute Myocardial Infarction Myocardial necrosis due to acuteocclusion of coronary artery
  • 6. Acute Coronary Syndrome Unstable Angina & AMI
  • 7. Factors infulencing myocardial oxygensupply and demandOXYGEN DEMANDCardiac work- Heart rate, blood pressure Myocardial contractility, LV hypertrophy
  • 8. OXYGEN SUPPLYCoronary blood flow Duration of diastole Coronary perfusion pressure Coronary vasomotor tone Oxygenation- haemoglobin oxygen saturation
  • 9. Activities precipitating anginaPhysical exertionCold exposureheavy mealsIntense emotionLying flatVivid dreams
  • 10. Risk stratification in stable anginaHIGH RISKPost infarction anginaPoor effort toleranceIschaemia at low work loadLt main or three vessel diseasePoor LV function
  • 11. Low riskPredictable exertional anginaGood effort toleranceIschaemia only at high workloadSingle or minor two vessel diseaseGood LV function
  • 12. Management of AnginaCareful assessment of the likely extent andseverity of arterial diseaseIdentification and control of significant riskfactorsUse of measure to control symptomsIdentification of high risk patients andapplication of treatment to improve lifeexpectancy
  • 13. Advice to patient with stable angina.Do not smoke.Ideal body weightregular exercise.Avoid severe , unaccustomed exercise,vigorous exercise after heavy meal or in verycold weather.Sublingual nitrate before exertion that mayinduce angina
  • 14. II. MEDICAL TREATMENTA. Symptomatic ( prevent or relieve angina Nitrates- Sublingual / buccal GTN Transdermal GTN Oral long acting ntrates (isosorbide mono/dinitrates) -Beta blockers- Atenolol 50-100 mg/d Metoprolol 25-50 mg/d
  • 15. -Ca channel blocker( when beta blocker is contra-indicatedor in case of coronary spasm)Nifedipine 5- 20 mg 8 hourlyNicardipine 20-40 mg 8 hourlyAmlodipine 2.5-10 mg odDiltiazem 60-120 mg 8 hourlyVerapamil 40-80 mg 8 hourly
  • 16. Potassium channel activatorNicorandil sodium 10-30 mg 12 hourly
  • 17. B. Prognostic treatment ( To improve long term prognosis andprevent coronary event ) -Asprin – 75-150 mg/d -Other antiplatelet – Clopidogrel( ifpatient can not tolerate asprin) 75 mg daily -Lipid lowering agents- Statins,Fibrates
  • 18. III. SURGICAL ( INVASIVE )TREATMENTA. Percutaneous Coronary Intervention-Balloon angioplasty-Implantation of coronary stent
  • 19. B. Coronary Artery Bypass Graft( CABG ) Antiplatelet ( Asprin andClopidogrel ) and aggressive lipidlowering therapy shown to slowprogression of disease in nativecoronary vessel and bypass graft
  • 20. Comparism of PCI and CABG PCI CABG Death 0.5% 1.5%MI 2% 10%Hospital stay 12-36 hour 5-8daysReturn to work 2-5 days 6-12weeksRecurrent angina 30% at 6 month 10% at 1 yearRecurrentrevascularisation 20% at 2 yr 2% at 2 yrNerologicalcomplication Rare commonOther complications Emergency CABG Diffuse myocardial Vascular damage damage Infection Wound pain
  • 21. Management ofAcute Myocardial Infarction
  • 22. DIAGNOSIS OF AMIAt least two of the followings - History of ischaemic type of chest pain - Evolving ECG changes - Rise and fall of cardiac enzymes
  • 23. ST Elevation Q wave
  • 24. CARDIAC ENZYMESEnzymes Peak PersistTroponin I 2-4 hours 7 daysCKMB within 24 hours 48 hoursSGOT ( AST ) 48 hours 72 hoursLDH 72 hours 10 days
  • 25. Treatment ofAcute Myocardial Infarction
  • 26. Acute conditionKeep in coronary care unit ( CCU )provide facilities for defibrillationHigh flow oxygenIV access and ECG monitor forarrhythmias
  • 27. Pain relief- IV morphine 10mg or diamorphine 5 mg with metoclopramide or cyclizineAsprin -300 mg chewed
  • 28. REPERFUSIONIV thrombolysis with Streptokinase 1.5million units over 1 hour (within 12 hourafter onset of chest pain)Other thrombolytic agents- r TPA
  • 29. Urgent PTCA As primary treatment Failed thrombolysis Contraindication to thrombolysis Re infarction
  • 30. Other treatments-IV atenolol – improve survival prevent myocardial ruptureIV nitrate infusion- for persistent painAnticoagulants( SC heparin) in addition tooral asprin may prevent reinfarction afterthrombolysis and prevent DVT andpulmonary embolism
  • 31. SUBSEQUENT MANAGEMENT( SECONDARY PREVENTION )Oral beta blocker ( atenolol ) if LV functionis goodACEI if LV function is poorAsprin 75-100 mg/d ay
  • 32. Lipid lowering therapyModification of risk factor –Smoking, exercise, dietPTAC or CABG
  • 33. ACUTE COMPLICATIONS OF AMICardiac arrestCardiac arrhythmias (especially ventricular arrhythmia )Cardiac conduction disturbance ( heart block )Cardiac failure- extensive myocardial infarctionCardiogenic shockPericarditis
  • 34. LATE COMPLICATIONS OF AMIRecurrent angina or infarctionThromboembolismMitral regurgitation – ruptured cordae tendinae/ papillary muscle dysfunctionVentricular free wall rupture- haemopericardiumVentricular aneurysmAcute ventricular septal defect
  • 35. Post-myocardial infarction syndrome(Dresslerssyndrome ) Immunological reaction-fever,arthralgia,pericarditis, pericardial effusionRecurrent arrhythmiasShoulder hand syndromePsychological- depression
  • 36. POOR PROGNOSTIC FACTORSOld ageLarge infarctPoor LV functionResidual myocardial ischaemiaVentricular arrhythmias