CAD

1. Coronary Artery Disease
• Chronic coronary syndrome
(Stable angina)
-chest pain on exertion and relieves with rest
• Acute coronary syndromes
(UA / STEMI, STEMI)

2. Cardiac chest pain
 Substernal/Retrosternal chest pain
 Crushing, constricting in nature
 Severe pain (Visual Analogue Score)
 Radiating to arm / jaw / neck / back /
abdomen
 Nausea and vomiting
 Dyspnoea
 Feeling faint
 Palpitations
Cllinical features
Signs
• Usually NORMAL
• AS murmur(ESM) , Pallor
• Rhythm abnormality( atrial flutter,
VF)
• Features of HF
(Crackles, oedema, hypotension,
new onset MR- papillary muscle
rupture)

3. Investigations
• ECG
1. Hyper acute T waves (1st to appear)
2. ST elevation (cardinal feature of MI)
3. T inversion
4. Pathological Q waves (late sign- indicate previously infarcted
myocardium)
5. New onset LBBB
6. Poor R wave progression
7. Heart blocks and tachyarrhythmias

5. • LV – Anterior V1 and V2
Septal V3 and V4
Lateral 1, AVL, V5 and V6
Posterior – R wave in V1 and V7 to V9
Inferior – 11, 111, AVF
• RV – V4R
• Reciprocal changes
• Other investigations
1) Myocardial necrosis – 12 Hour Troponin and CKMB and LDH
- Troponin start to rise in 6 hrs, peaks by 12 hours, remains for 7 days
2) Wall motion abnormalities – Echo, MRI
3) Ischaemia – Nuclear perfusion scan

6. A) Treatment of STEMI
Factors determining patient survival
1. Establishing brisk anterograde coronary flow beyond the thrombus
2. Time taken to achieve this
3. Sustained patency of affected artery
Management of ACS

7. 1. Anti-platelet therapy
• Aspirin 300 mg stat
• P2Y12 inhibitors (for one year)
1) Prasugrel – 60 mg stat and 10mg/d LT
(CI in stroke and older than 75 due to high
bleeding risk)
1) Ticagrelor – 180 mg stat and 90 mg bid LT
2) Clopidogrel 300 mg stat and 75 mg/d LT
1)Thrombolysis with
Streptokinase, Alteplase
Reteplase or Tenecteplase
2) Primary PTCA
(percutaneous transluminal
coronary angioplasty) also
called PCI(Percutaneous
coronary intervention)
3) CABG
2. Acute Reperfusion
theraphy

8. Absolute contraindications
to thrombolysis
• Cerebral haemorrhage at any time
• Non haemorrhagic stroke within the past one year
• Blood pressure > 180/110
• Suspicion of aortic dissection
• Recent major surgery – less than 2 weeks
• Active internal bleeding (except menses)
• No streptokinase if that has been given within past 5 days to 2 years

9. • Current use of anticoagulants (INR > 2)
• Surgery within past 2 weeks
• Prolonged CPR (>10 min) within past 2 weeks
• Bleeding diathesis
• Pregnancy
• Haemorrhagic ophthalmic condition (DR)
• Active peptic ulcer disease
Relative contraindications – Risk vs Benefit
analysis needed

10. Primary angioplasty
• Better than thrombolysis, to be done within 12 hours
• Re-canalisation rate of 95%
• Rescue angioplasty*
• Adjunctive angioplasty*- NO
• Only to selected patients who are unsuitable for or not responding to
thrombolysis and PTCA
• Triple vessel disease and severe left coronary artery disease- may
need CABG
CABG

11. Other medications -
• Sublingual GTN up to 3 doses for chest pain. (IV GTN if response is
poor)- hypotension
• Morphine 2.5 mg IV bolus doses every 5 minutes till pain relieved-
respiratory depression (monitor)
• Beta blockers – Metoprolol 25-50 mg bid PO or Carvedilol 6.25 mg
bid PO
• ACE Inhibitors for all STEMIs
• High dose Statins – Atorvastatin 40-80 mg per day

12. No nitrates for
Although nitrates are the first line for ischemic chest pain its avoided in
following 3 conditions:
• SBP < 90 mmHg- risk of profound systemic hypotension
• Taken PDE-5 inhibitors(Sildenafil) within past 24 hours
• RV infarct (Inferior MI, hypotension, raised JVP and clear lungs)*

13. B) Treatment of NSTEMI and UA
• Aim – alleviate chest pain and prevent STEMI
• NO place for Thrombolytic therapy (Fibrinolysis is harmful)
• Mainstays of treatment
1) Anti-platelet therapy
2) Anticoagulation – does not dissolve the blood clot
but prevents progression (Unfractionated heparin/
LMWH
3) Other medications
4) Coronary interventions( PCI last option here unlike in STEMI)

14. 1. Anti-Platelet therapy
• Aspirin 300 mg stat and continue at 75 mg nocte
• P2Y12 Inhibitors
1) Clopidogrel – 300 mg stat and 75 mg nocte
2) Ticagrelor – Faster action than
Clopidogrel. More effective as well
3) Prasugrel* – For patients who are undergoing coronary stenting
procedures
• Glycoprotein 11B/111A Inhibitors
Given as infusions to high risk patients
1) Tirofiban
2) Eptifibide

15. 2. Anticoagulation –
1) Heparin Unfractionated
• Bolus IV followed by infusion (12-15U / kg of body weight) for 48 – 72
hours
• Dose adjusted with 6 hourly APTT monitoring
• Aim to keep APTT between X 1.5-2.5 (approx 25-35 seconds)
- But now we have LMWH which is much easier to be given

16. 2) Heparin – LMWH
• Enoxaparin and Dalteparin
• SC injections, twice daily, dose calculated according to weight
• No monitoring necessary

17. 3) Fondaparinux
• Factor Xa inhibitor
• 2.5 mg SC OD
• Lower bleeding risk than Heparin
• Bivalirudin (rarely used not in our setting)
• Less bleeding risk
4) Direct Thrombin Inhibitors

18. 3. Other therapies
• Nitroglycerin
1st line for chest pain.
Oral, sublingual, ointment and IV.
IV dose – 10 to 200 mcg/min.
Avoid SBP < 100
IV Nitoglycerin- A/E- Profound hypotension and Headache
• Beta-blockers – Metoprolol oral / IV
• CCB – third line, only if betablockers are CI
• Statins – High dose – Atorvastatin 40-80 mg/d

19. 4. Last resort – PTCA
• For high risk patients only.
• Place for routine PTCA for NSTEMI and UA – Not established. May be
only as useful as optimal medical therapy

21. Primary prevention of CAD in patients with
Diabetes Mellitus
Lifestyle modification
Weight reduction
• Weight reduction in obese patients will reduce all of the CAD risk
factors associated with type 2 diabetes mellitus and will improve
hyperglycemia.
• Moderate weight loss (eg, 7% to 10% of body weight in 1 year) is
often attainable & recommended.
• Even if no weight reduction can be achieved, weight maintenance is
certainly preferable to weight gain.

22. Medical Nutrition Therapy
• The best mix of carbohydrate, protein, and fat seems to vary
according to individual circumstances.
• The restriction of saturated fats, dietary cholesterol, and trans-
unsaturated fats and the incorporation of increased dietary fiber
and monounsaturated and polyunsaturated fats into the diet are
recommended dietary strategies to improve lipids.
• Supplementation of a healthy diet with antioxidant vitamins, B
vitamins to lower homocysteine, or specific fatty acids (such as
omega-3 fatty acids) has been demonstrated to be associated with
lower CVD risk in published epidemiological analyses.

23. • The strongest data for benefit are with omega-3 fatty acids in
individuals with established CAD.
• For this reason, the AHA currently recommends 1 g/d
eicosapentaenoic acid + docosahexaenoic acid for individuals
with established disease.
Physical Activity
• At least 150 minutes of moderate-intensity aerobic physical activity or at
least 90 minutes of vigorous aerobic exercise per week is recommended.
The physical activity should be distributed over at least 3 days per week,
with no more than 2 consecutive days without physical activity.
•For long-term maintenance of major weight loss, a larger amount of
exercise (7 hours of moderate or vigorous aerobic physical activity per
week) may be helpful.

24. • Alcohol & Smoking
• If individuals choose to drink alcohol, daily intake should be
limited to 1 drink for adult women and 2 drinks for adult men.
One drink is defined as a 12-oz beer, a 4-oz glass of wine, or a
1.5-oz glass of distilled spirits.
• Alcohol ingestion increases caloric intake and should be
minimized when weight loss is the goal. Individuals with
elevated plasma triglyceride levels should limit alcohol intake
because intake may exacerbate hypertriglyceridemia.
• Alcohol ingestion can also increase blood pressure

25. • Every tobacco user should be advised to quit.
• The tobacco user’s willingness to quit should be assessed.
• The patient can be assisted by counseling and by developing a
cessation plan.
• Follow-up, referral to special programs, or pharmacotherapy
(including nicotine replacement and bupropion) should be
incorporated as needed.

26. Glycemic Control
Glycemic control clearly reduces microvascular complications in
patients with diabetes
However, one of the most debated clinical questions in diabetes
is whether better glycemic control is associated with a reduction
in CVD outcomes and how low we should go in pursuing
glycemic targets
• The A1c goal for patients in general is <7%.
• The A1c goal for the individual patient is as close to normal
(<6%) as possible without causing significant hypoglycemia.

27. • Lipids
• In adult patients, lipid levels should be measured at least annually
and more often if needed to achieve goals. In adults under the age
of 40 years with low-risk lipid values (LDL-C <100 mg/dL, HDL-C >50
mg/dL, and triglycerides <150 mg/dL), lipid assessments may be
repeated every 2 years.
• Patients should focus on the reduction of saturated fat and
cholesterol intake, weight loss (if indicated), and increases in
dietary fiber and physical activity. These lifestyle changes have
been shown to improve the lipid profile in patients with diabetes.
• Combination therapy of LDL-lowering drugs (eg, statins) with
fibrates or niacin may be necessary to achieve lipid targets, but this
has not been evaluated in outcomes studies for either CVD event
reduction or safety.

28. Blood pressure control
• Patients with diabetes – Target SBP <130 mm Hg and a DBP<80 mm Hg.
• Patients with a SBP of 130 -139 mm Hg or a DBP of 80- 89 mm Hg should
initiate lifestyle modification alone for a maximum of 3 months. If, targets
not achieved, treatment with pharmacological agents.
• Patients with hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg) should
receive drug therapy in addition to lifestyle modification
• All patients with diabetes and hypertension should be treated with a
regimen that includes either an ACE inhibitor or an ARB. If one class is not
tolerated, the other should be substituted. Other drug classes
demonstrated to reduce CVD events in patients with diabetes (β-blockers,
thiazide diuretics, and calcium channel blockers) should be added as
needed to achieve blood pressure targets.

29. Antiplatelet Therapy
• Aspirin therapy (75 to 162 mg/d) should be recommended as a
primary prevention strategy in those with diabetes at increased
cardiovascular risk, including those who are >40 years of age or
who have additional risk factors (family history of CVD,
hypertension, smoking, dyslipidemia, or albuminuria).
• People with aspirin allergy, bleeding tendency, existing
anticoagulant therapy, recent gastrointestinal bleeding, and
clinically active hepatic disease are not candidates for aspirin
therapy. Other antiplatelet agents may be a reasonable
alternative for patients at high risk.