This document discusses stable and acute ischemic heart disease. It begins by defining coronary heart disease and coronary artery disease. It then discusses the etiology, pathophysiology, risk factors, classification, clinical presentation, and desired outcomes of stable ischemic heart disease. It covers the general treatment approach including risk factor modification, drug therapy using antiplatelet agents, ACE inhibitors, statins, beta-blockers, calcium channel blockers, and nitrates. It then discusses acute coronary syndromes including unstable angina, non-ST-elevation myocardial infarction, and ST-elevation myocardial infarction. It covers risk stratification, general treatment approach, and early pharmacotherapy for ST-elevation myocardial infarction.
Angina is caused by an imbalance in myocardial oxygen supply and demand. It is usually due to coronary artery disease which decreases oxygen supply. Antianginal drugs work to improve this balance by either dilating coronary arteries to increase supply or reducing demands on the heart to decrease oxygen needs. The main drug classes used are nitrates, beta blockers, and calcium channel blockers. Combination therapy with two or more classes is often used if single drug therapy is insufficient. Other treatment options include percutaneous coronary intervention to open blocked arteries or coronary artery bypass graft surgery to create new routes for blood flow around blockages.
This document discusses antianginal drugs used to treat angina pectoris, or chest pain caused by reduced blood flow to the heart. There are three main classes of drugs used: organic nitrates, beta-blockers, and calcium channel blockers. Organic nitrates like nitroglycerin work by dilating blood vessels to increase blood flow to the heart and reduce its workload. Beta-blockers lower the heart rate and force of contraction to decrease oxygen demand. Calcium channel blockers inhibit calcium entry into heart and blood vessel cells to relax vessels and reduce workload. Each drug class is described in more detail regarding mechanisms, effects, pharmacokinetics, uses, and side effects.
This document discusses angina pectoris, its causes, symptoms, diagnosis and management. It provides details on:
- Angina is caused by transient myocardial ischemia due to an imbalance of oxygen supply and demand in the heart. The most common cause is atherosclerosis.
- Risk factors, symptoms, and physical exam findings for angina are described. Management involves identifying and treating risk factors, introducing anti-anginal drugs, and considering revascularization if drugs do not control symptoms.
- Five main classes of anti-anginal drugs are discussed - nitrates, beta-blockers, calcium channel blockers, potassium channel activators, and ivabradine. Their mechanisms of action and usage guidelines are
This document provides an overview of drugs used to treat ischemic heart disease (IHD). IHD is caused by a lack of oxygenated blood flow to the heart muscle and includes stable angina and acute coronary syndromes. Nitrates like nitroglycerin are first-line for acute angina by reducing cardiac preload and oxygen demand. Long-term nitrate use leads to tolerance, so alternatives like beta-blockers and calcium channel blockers are preferred for maintenance. Antiplatelets like aspirin and P2Y12 inhibitors prevent clots in acute coronary syndromes. Heparin also reduces clotting during instability. Thrombolytics restore blood flow in acute myocardial infarction.
This document discusses drugs used for the treatment of ischemic heart disease (IHD). IHD is caused by a lack of oxygenated blood flow to the heart muscle and includes stable angina and acute coronary syndromes. Nitrates, beta blockers, and calcium channel blockers are first-line treatments for stable angina by reducing oxygen demand on the heart and dilating blood vessels. Nitrates work primarily by venous dilation to reduce preload, while beta blockers lower heart rate and contractility. Calcium channel blockers inhibit calcium influx. For unstable angina/acute coronary syndromes, antiplatelet agents like aspirin are also used to prevent clots.
Stable ischemic heart disease is typically caused by atherosclerotic plaques narrowing the coronary arteries and reducing blood flow to the heart muscle. It commonly manifests as chronic stable angina or silent ischemia. The goals of treatment are to eliminate chest pain, slow atherosclerosis progression, and prevent complications like heart attack. Treatment involves lifestyle modifications, risk factor control through medications, and sometimes revascularization. Pharmacologic options for management include antiplatelet agents, beta-blockers, calcium channel blockers, ACE inhibitors, and long-acting nitrates.
This document discusses antianginal drugs used to treat angina pectoris and coronary artery disease. It describes the types and causes of angina, the classes of antianginal drugs including their mechanisms of action, effects, examples, and uses. The main classes discussed are nitrates, beta blockers, calcium channel blockers, and potassium channel openers. Adverse effects and pharmacokinetics are also summarized for several drug classes and examples.
Angina is caused by an imbalance in myocardial oxygen supply and demand. It is usually due to coronary artery disease which decreases oxygen supply. Antianginal drugs work to improve this balance by either dilating coronary arteries to increase supply or reducing demands on the heart to decrease oxygen needs. The main drug classes used are nitrates, beta blockers, and calcium channel blockers. Combination therapy with two or more classes is often used if single drug therapy is insufficient. Other treatment options include percutaneous coronary intervention to open blocked arteries or coronary artery bypass graft surgery to create new routes for blood flow around blockages.
This document discusses antianginal drugs used to treat angina pectoris, or chest pain caused by reduced blood flow to the heart. There are three main classes of drugs used: organic nitrates, beta-blockers, and calcium channel blockers. Organic nitrates like nitroglycerin work by dilating blood vessels to increase blood flow to the heart and reduce its workload. Beta-blockers lower the heart rate and force of contraction to decrease oxygen demand. Calcium channel blockers inhibit calcium entry into heart and blood vessel cells to relax vessels and reduce workload. Each drug class is described in more detail regarding mechanisms, effects, pharmacokinetics, uses, and side effects.
This document discusses angina pectoris, its causes, symptoms, diagnosis and management. It provides details on:
- Angina is caused by transient myocardial ischemia due to an imbalance of oxygen supply and demand in the heart. The most common cause is atherosclerosis.
- Risk factors, symptoms, and physical exam findings for angina are described. Management involves identifying and treating risk factors, introducing anti-anginal drugs, and considering revascularization if drugs do not control symptoms.
- Five main classes of anti-anginal drugs are discussed - nitrates, beta-blockers, calcium channel blockers, potassium channel activators, and ivabradine. Their mechanisms of action and usage guidelines are
This document provides an overview of drugs used to treat ischemic heart disease (IHD). IHD is caused by a lack of oxygenated blood flow to the heart muscle and includes stable angina and acute coronary syndromes. Nitrates like nitroglycerin are first-line for acute angina by reducing cardiac preload and oxygen demand. Long-term nitrate use leads to tolerance, so alternatives like beta-blockers and calcium channel blockers are preferred for maintenance. Antiplatelets like aspirin and P2Y12 inhibitors prevent clots in acute coronary syndromes. Heparin also reduces clotting during instability. Thrombolytics restore blood flow in acute myocardial infarction.
This document discusses drugs used for the treatment of ischemic heart disease (IHD). IHD is caused by a lack of oxygenated blood flow to the heart muscle and includes stable angina and acute coronary syndromes. Nitrates, beta blockers, and calcium channel blockers are first-line treatments for stable angina by reducing oxygen demand on the heart and dilating blood vessels. Nitrates work primarily by venous dilation to reduce preload, while beta blockers lower heart rate and contractility. Calcium channel blockers inhibit calcium influx. For unstable angina/acute coronary syndromes, antiplatelet agents like aspirin are also used to prevent clots.
Stable ischemic heart disease is typically caused by atherosclerotic plaques narrowing the coronary arteries and reducing blood flow to the heart muscle. It commonly manifests as chronic stable angina or silent ischemia. The goals of treatment are to eliminate chest pain, slow atherosclerosis progression, and prevent complications like heart attack. Treatment involves lifestyle modifications, risk factor control through medications, and sometimes revascularization. Pharmacologic options for management include antiplatelet agents, beta-blockers, calcium channel blockers, ACE inhibitors, and long-acting nitrates.
This document discusses antianginal drugs used to treat angina pectoris and coronary artery disease. It describes the types and causes of angina, the classes of antianginal drugs including their mechanisms of action, effects, examples, and uses. The main classes discussed are nitrates, beta blockers, calcium channel blockers, and potassium channel openers. Adverse effects and pharmacokinetics are also summarized for several drug classes and examples.
This document discusses various drugs used to treat angina pectoris. It begins by defining angina and describing its causes as inadequate blood flow through the coronary arteries. It then discusses the different types of angina - stable, unstable, and Prinzmetal's variant angina. The main drugs used to treat angina are described - nitrates, beta-blockers, calcium channel blockers, and newer drugs like ranolazine. Nitrates work by dilating blood vessels to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium entry to arteries and heart muscle. Ranolazine inhibits sodium channels to reduce oxygen demand. Combinations of these drugs
This document discusses the pharmacology of antianginal drugs. It begins by defining angina pectoris and the two principal forms - classical angina and variant/Prinzmetal angina. It then covers the mechanisms of action and classifications of major classes of antianginal drugs, including nitrates, beta blockers, calcium channel blockers, potassium channel openers, and others like dipyridamole and trimetazidine. Specific drugs within each class are discussed in terms of their mechanisms, effects, uses, and adverse effects. The history and mechanisms of calcium channel blockers and their subclasses are described in detail.
Anti-Angina & Anti arryhthias Drugs .pptssuser504dda
This document discusses drugs used to manage angina and arrhythmias, and current guidelines for managing acute coronary syndrome (ACS). It describes the classification and pathophysiology of angina, then focuses on pharmacological management including nitrates like nitroglycerin, calcium channel blockers like nifedipine, beta blockers like atenolol, and alpha/beta blockers like carvedilol. It provides details on their mechanisms of action, indications, interactions, and side effects in treating conditions like angina, heart failure and ACS.
Coronary artery disease is caused by a narrowing or blockage of the coronary arteries due to atherosclerosis. It is the leading cause of death worldwide. Risk factors include high blood pressure, diabetes, smoking, high cholesterol, obesity, and family history. The rupture of atherosclerotic plaque leads to thrombus formation, which can reduce blood flow and cause myocardial ischemia. Angina occurs when there is an imbalance between oxygen supply and demand in the heart. Management involves risk factor modification, antiplatelet/statin therapy, and antianginal drugs like nitrates, beta-blockers, and calcium channel blockers to reduce symptoms. Non-pharmacological options include procedures like stents and bypass surgery.
Ischemic heart disease occurs when coronary arteries become narrowed by atherosclerosis, reducing blood flow to the heart muscle. Angina, myocardial ischemia, and myocardial infarction can result. Myocardial infarction is caused by sudden blockage of a coronary artery and leads to cell death in the affected region. Treatment focuses on pain relief, oxygenation, volume maintenance, acidosis correction, and preventing/treating arrhythmias. Drugs like nitrates, beta blockers, and calcium channel blockers aim to reduce oxygen demand and increase supply.
anti anginal drugs and side affect and Symptomswajidullah9551
This document discusses different types of angina pectoris and antianginal drugs. It describes typical angina, variant angina, and unstable angina. The main classes of antianginal drugs covered are nitrates, beta-blockers, calcium channel blockers, and potassium channel openers. Nitrates work by vasodilation to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium influx to relax smooth muscle. Potassium channel openers like nicorandil dilate blood vessels.
Ischemic heart disease, also known as coronary artery disease, is caused by a reduced blood supply to the heart muscle due to narrowed or blocked coronary arteries. It can lead to chest pain called angina or a heart attack if a complete blockage occurs. Risk factors include smoking, high blood pressure, diabetes, and high cholesterol. Diagnosis involves electrocardiograms, echocardiograms, stress tests, and angiograms. Treatment includes medications to relieve symptoms and open blocked arteries as well as procedures like angioplasty and bypass surgery. Adopting a healthy lifestyle can help prevent ischemic heart disease.
This document discusses different types of angina and drugs used to treat them. It defines angina as chest pain caused by inadequate blood flow to the heart. The main types of angina discussed are stable angina, unstable angina, and Prinzmetal's variant angina. The document outlines several classes of drugs used to treat angina, including nitrates, beta-blockers, calcium channel blockers, and some newer drugs. It provides details on the mechanisms and effects of these drug classes and recommendations for treating different angina types.
This document summarizes different drugs used to treat angina. It first defines angina as chest pain caused by inadequate blood flow to the heart muscle. The main drugs discussed are:
1. Nitrate esters like nitroglycerin, which work by dilating blood vessels to increase blood flow and decrease workload on the heart.
2. Beta-blockers like propranolol, which work by blocking beta-1 receptors to reduce heart rate, blood pressure, and cardiac workload.
3. Calcium channel blockers like verapamil, which work by blocking calcium channels in heart and blood vessels to reduce contraction and dilate vessels, also reducing workload on the heart.
These
Anti Anginal Drugs and its side affect and useswajidullah9551
This document discusses anti-anginal drugs used to treat angina pectoris. There are three main classes of drugs: nitrates, beta blockers, and calcium channel blockers. Nitrates work by reducing preload and afterload, increasing coronary blood flow and oxygen supply. Beta blockers decrease oxygen demand by lowering heart rate and contractility. Calcium channel blockers increase oxygen supply by dilating coronary arteries and reduce afterload by decreasing peripheral resistance. The document provides details on the mechanisms, effects, and examples of drugs in each class.
This document discusses angina pectoris, a common symptom of coronary artery disease where chest pain occurs due to reduced blood flow to the heart. It first covers the pathophysiology where an imbalance between oxygen supply and demand causes myocardial ischemia. Signs and symptoms including chest discomfort that can radiate to other areas and is exacerbated by exertion. Causes include risk factors like diabetes and hypertension. Diagnostic tests evaluate for coronary artery disease and include ECG, stress tests, and angiograms. Treatment involves lifestyle changes, medications like nitrates, beta blockers, and calcium channel blockers to reduce symptoms, and potentially surgeries like angioplasty or bypass grafting.
This document discusses angina pectoris, also known as stable angina. It defines angina as chest pain or discomfort that occurs due to decreased blood flow to the heart muscle. It then describes the different types of angina and their causes. The main causes are atherosclerosis, coronary artery spasm, traumatic injury, and embolic events which can all restrict blood flow to the heart. The document outlines the goals of treatment which are to prevent heart attacks and death while reducing angina symptoms. It then discusses the various pharmacological treatments used including nitrates, beta blockers, calcium channel blockers, antiplatelet agents, ACE inhibitors, and ranolazine. Non-pharmacological options like percutaneous coronary
Coronary circulation supplies oxygenated blood to the heart muscle through coronary arteries and drains deoxygenated blood away through cardiac veins. Interruptions in coronary circulation can cause heart attacks. Angina pectoris is chest pain that occurs when part of the heart doesn't get enough blood and oxygen, and can be a symptom of coronary artery disease. There are three types of angina pectoris: stable angina, unstable angina, and Prinzmetal angina. Treatment of angina aims to balance oxygen supply and demand through drugs like nitrates, beta-blockers, and calcium channel blockers.
This document discusses coronary artery disease (CAD) and angina. It provides information on:
1. CAD is the most common form of heart disease and a leading cause of death worldwide. It is caused by atheroma and thrombosis in the coronary arteries.
2. Risk factors for CAD include high cholesterol, high blood pressure, smoking, obesity, diabetes, lack of exercise, and genetics.
3. Angina is chest pain caused by transient myocardial ischemia due to an imbalance between oxygen supply and demand in the heart. Nitrates and calcium channel blockers are commonly used to treat angina by reducing cardiac workload and increasing blood flow.
PH1.28 Describe the mechanisms of action, types, doses, side effects, indicat...Dr Pankaj Kumar Gupta
PH1.28 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in ischemic heart disease (stable, unstable angina and myocardial infarction), peripheral vascular disease
The term ischemic heart disease (IHD) describes a group of clinical syndromes characterized by myocardial ischemia, an imbalance between myocardial blood supply and demand.
Because the fundamental pathophysiologic defect in the ischemic myocardium is inadequate perfusion, ischemia is associated not only with insufficient oxygen supply, but also with reduced availability of nutrients and inadequate removal of metabolic end products.
Ischemic heart disease (IHD) caused by atherosclerosis of the epicardial vessels leading to coronary heart disease (CHD) is the main etiology of IHD.
Leading cause of death
Resulting from myocardial ischemia—an imbalance between the supply (perfusion) and demand of the heart for oxygenated blood.
90% of cases, the cause of myocardial ischemia is reduced blood flow due to obstructive atherosclerotic lesions in the coronary arteries.
IHD is often termed coronary artery disease (CAD) or coronary heart disease.
There is a long period (up to decades) of silent, slow progression of coronary lesions before symptoms appear.
IHD are only the late manifestations of coronary atherosclerosis that may have started during childhood or adolescence
Myocardial infarction, the most important form of IHD, in which ischemia causes the death of heart muscle.
Angina pectoris, in which the ischemia is of insufficient severity to cause infarction, but may be a harbinger of MI.
Chronic IHD with heart failure.
Sudden cardiac death.
The dominant cause of the IHD syndromes is insufficient coronary perfusion relative to myocardial demand, due to • Chronic, progressive atherosclerotic narrowing of the epicardial coronary arteries, and • Variable degrees of superimposed acute plaque change, thrombosis, and vasospasm
Clinical manifestations of coronary atherosclerosis are generally due to • Progressive narrowing of the lumen leading to stenosis (“fixed” obstructions) or • Acute plaque disruption with thrombosis, both of which compromise blood flow.
A fixed lesion obstructing 75% or greater of the lumen is generally required to cause symptomatic ischemia precipitated by exercise (most often manifested as chest pain, known as angina)
Obstruction of 90% of the lumen can lead to inadequate coronary blood flow even at rest.
This document discusses different types of angina and treatments. It describes 3 main types of angina: atherosclerotic angina which is caused by partially blocked arteries and accounts for 90% of cases; vasospastic angina which involves coronary artery spasms and can occur at rest; and unstable angina which is a medical emergency and precursor to heart attack. The major treatment strategies aim to increase oxygen delivery to the heart and reduce oxygen demand. Traditional pharmacological therapies discussed include nitrates, calcium channel blockers, and beta blockers which all work to relax blood vessels or reduce heart rate to improve oxygen supply. Newer drugs like ranolazine and ivabradine are also mentioned.
Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much blood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.
This document discusses gout and hyperuricemia. It defines gout as a type of inflammatory arthritis caused by uric acid crystals depositing in joints. Gout is associated with hyperuricemia, an elevated uric acid level. The document reviews risk factors, pathophysiology, clinical presentation, diagnosis, and treatment approaches including lifestyle changes, medications to treat acute attacks, and long-term urate-lowering therapy. It provides details on medications commonly used to treat gout such as allopurinol, febuxostat, colchicine, NSAIDs, and corticosteroids.
The document defines shock and describes its various types, including hypovolemic, cardiogenic, obstructive, and distributive shock. It discusses the pathophysiology, clinical presentation, diagnosis, and general treatment approach for shock. Regarding treatment, it emphasizes early correction of pulse, ventilation, oxygenation, and fluid administration. It then provides specific protocols for resuscitation in cases of hypovolemia and septic shock.
This document discusses various drugs used to treat angina pectoris. It begins by defining angina and describing its causes as inadequate blood flow through the coronary arteries. It then discusses the different types of angina - stable, unstable, and Prinzmetal's variant angina. The main drugs used to treat angina are described - nitrates, beta-blockers, calcium channel blockers, and newer drugs like ranolazine. Nitrates work by dilating blood vessels to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium entry to arteries and heart muscle. Ranolazine inhibits sodium channels to reduce oxygen demand. Combinations of these drugs
This document discusses the pharmacology of antianginal drugs. It begins by defining angina pectoris and the two principal forms - classical angina and variant/Prinzmetal angina. It then covers the mechanisms of action and classifications of major classes of antianginal drugs, including nitrates, beta blockers, calcium channel blockers, potassium channel openers, and others like dipyridamole and trimetazidine. Specific drugs within each class are discussed in terms of their mechanisms, effects, uses, and adverse effects. The history and mechanisms of calcium channel blockers and their subclasses are described in detail.
Anti-Angina & Anti arryhthias Drugs .pptssuser504dda
This document discusses drugs used to manage angina and arrhythmias, and current guidelines for managing acute coronary syndrome (ACS). It describes the classification and pathophysiology of angina, then focuses on pharmacological management including nitrates like nitroglycerin, calcium channel blockers like nifedipine, beta blockers like atenolol, and alpha/beta blockers like carvedilol. It provides details on their mechanisms of action, indications, interactions, and side effects in treating conditions like angina, heart failure and ACS.
Coronary artery disease is caused by a narrowing or blockage of the coronary arteries due to atherosclerosis. It is the leading cause of death worldwide. Risk factors include high blood pressure, diabetes, smoking, high cholesterol, obesity, and family history. The rupture of atherosclerotic plaque leads to thrombus formation, which can reduce blood flow and cause myocardial ischemia. Angina occurs when there is an imbalance between oxygen supply and demand in the heart. Management involves risk factor modification, antiplatelet/statin therapy, and antianginal drugs like nitrates, beta-blockers, and calcium channel blockers to reduce symptoms. Non-pharmacological options include procedures like stents and bypass surgery.
Ischemic heart disease occurs when coronary arteries become narrowed by atherosclerosis, reducing blood flow to the heart muscle. Angina, myocardial ischemia, and myocardial infarction can result. Myocardial infarction is caused by sudden blockage of a coronary artery and leads to cell death in the affected region. Treatment focuses on pain relief, oxygenation, volume maintenance, acidosis correction, and preventing/treating arrhythmias. Drugs like nitrates, beta blockers, and calcium channel blockers aim to reduce oxygen demand and increase supply.
anti anginal drugs and side affect and Symptomswajidullah9551
This document discusses different types of angina pectoris and antianginal drugs. It describes typical angina, variant angina, and unstable angina. The main classes of antianginal drugs covered are nitrates, beta-blockers, calcium channel blockers, and potassium channel openers. Nitrates work by vasodilation to reduce preload and afterload. Beta-blockers reduce heart rate and contractility. Calcium channel blockers inhibit calcium influx to relax smooth muscle. Potassium channel openers like nicorandil dilate blood vessels.
Ischemic heart disease, also known as coronary artery disease, is caused by a reduced blood supply to the heart muscle due to narrowed or blocked coronary arteries. It can lead to chest pain called angina or a heart attack if a complete blockage occurs. Risk factors include smoking, high blood pressure, diabetes, and high cholesterol. Diagnosis involves electrocardiograms, echocardiograms, stress tests, and angiograms. Treatment includes medications to relieve symptoms and open blocked arteries as well as procedures like angioplasty and bypass surgery. Adopting a healthy lifestyle can help prevent ischemic heart disease.
This document discusses different types of angina and drugs used to treat them. It defines angina as chest pain caused by inadequate blood flow to the heart. The main types of angina discussed are stable angina, unstable angina, and Prinzmetal's variant angina. The document outlines several classes of drugs used to treat angina, including nitrates, beta-blockers, calcium channel blockers, and some newer drugs. It provides details on the mechanisms and effects of these drug classes and recommendations for treating different angina types.
This document summarizes different drugs used to treat angina. It first defines angina as chest pain caused by inadequate blood flow to the heart muscle. The main drugs discussed are:
1. Nitrate esters like nitroglycerin, which work by dilating blood vessels to increase blood flow and decrease workload on the heart.
2. Beta-blockers like propranolol, which work by blocking beta-1 receptors to reduce heart rate, blood pressure, and cardiac workload.
3. Calcium channel blockers like verapamil, which work by blocking calcium channels in heart and blood vessels to reduce contraction and dilate vessels, also reducing workload on the heart.
These
Anti Anginal Drugs and its side affect and useswajidullah9551
This document discusses anti-anginal drugs used to treat angina pectoris. There are three main classes of drugs: nitrates, beta blockers, and calcium channel blockers. Nitrates work by reducing preload and afterload, increasing coronary blood flow and oxygen supply. Beta blockers decrease oxygen demand by lowering heart rate and contractility. Calcium channel blockers increase oxygen supply by dilating coronary arteries and reduce afterload by decreasing peripheral resistance. The document provides details on the mechanisms, effects, and examples of drugs in each class.
This document discusses angina pectoris, a common symptom of coronary artery disease where chest pain occurs due to reduced blood flow to the heart. It first covers the pathophysiology where an imbalance between oxygen supply and demand causes myocardial ischemia. Signs and symptoms including chest discomfort that can radiate to other areas and is exacerbated by exertion. Causes include risk factors like diabetes and hypertension. Diagnostic tests evaluate for coronary artery disease and include ECG, stress tests, and angiograms. Treatment involves lifestyle changes, medications like nitrates, beta blockers, and calcium channel blockers to reduce symptoms, and potentially surgeries like angioplasty or bypass grafting.
This document discusses angina pectoris, also known as stable angina. It defines angina as chest pain or discomfort that occurs due to decreased blood flow to the heart muscle. It then describes the different types of angina and their causes. The main causes are atherosclerosis, coronary artery spasm, traumatic injury, and embolic events which can all restrict blood flow to the heart. The document outlines the goals of treatment which are to prevent heart attacks and death while reducing angina symptoms. It then discusses the various pharmacological treatments used including nitrates, beta blockers, calcium channel blockers, antiplatelet agents, ACE inhibitors, and ranolazine. Non-pharmacological options like percutaneous coronary
Coronary circulation supplies oxygenated blood to the heart muscle through coronary arteries and drains deoxygenated blood away through cardiac veins. Interruptions in coronary circulation can cause heart attacks. Angina pectoris is chest pain that occurs when part of the heart doesn't get enough blood and oxygen, and can be a symptom of coronary artery disease. There are three types of angina pectoris: stable angina, unstable angina, and Prinzmetal angina. Treatment of angina aims to balance oxygen supply and demand through drugs like nitrates, beta-blockers, and calcium channel blockers.
This document discusses coronary artery disease (CAD) and angina. It provides information on:
1. CAD is the most common form of heart disease and a leading cause of death worldwide. It is caused by atheroma and thrombosis in the coronary arteries.
2. Risk factors for CAD include high cholesterol, high blood pressure, smoking, obesity, diabetes, lack of exercise, and genetics.
3. Angina is chest pain caused by transient myocardial ischemia due to an imbalance between oxygen supply and demand in the heart. Nitrates and calcium channel blockers are commonly used to treat angina by reducing cardiac workload and increasing blood flow.
PH1.28 Describe the mechanisms of action, types, doses, side effects, indicat...Dr Pankaj Kumar Gupta
PH1.28 Describe the mechanisms of action, types, doses, side effects, indications and contraindications of the drugs used in ischemic heart disease (stable, unstable angina and myocardial infarction), peripheral vascular disease
The term ischemic heart disease (IHD) describes a group of clinical syndromes characterized by myocardial ischemia, an imbalance between myocardial blood supply and demand.
Because the fundamental pathophysiologic defect in the ischemic myocardium is inadequate perfusion, ischemia is associated not only with insufficient oxygen supply, but also with reduced availability of nutrients and inadequate removal of metabolic end products.
Ischemic heart disease (IHD) caused by atherosclerosis of the epicardial vessels leading to coronary heart disease (CHD) is the main etiology of IHD.
Leading cause of death
Resulting from myocardial ischemia—an imbalance between the supply (perfusion) and demand of the heart for oxygenated blood.
90% of cases, the cause of myocardial ischemia is reduced blood flow due to obstructive atherosclerotic lesions in the coronary arteries.
IHD is often termed coronary artery disease (CAD) or coronary heart disease.
There is a long period (up to decades) of silent, slow progression of coronary lesions before symptoms appear.
IHD are only the late manifestations of coronary atherosclerosis that may have started during childhood or adolescence
Myocardial infarction, the most important form of IHD, in which ischemia causes the death of heart muscle.
Angina pectoris, in which the ischemia is of insufficient severity to cause infarction, but may be a harbinger of MI.
Chronic IHD with heart failure.
Sudden cardiac death.
The dominant cause of the IHD syndromes is insufficient coronary perfusion relative to myocardial demand, due to • Chronic, progressive atherosclerotic narrowing of the epicardial coronary arteries, and • Variable degrees of superimposed acute plaque change, thrombosis, and vasospasm
Clinical manifestations of coronary atherosclerosis are generally due to • Progressive narrowing of the lumen leading to stenosis (“fixed” obstructions) or • Acute plaque disruption with thrombosis, both of which compromise blood flow.
A fixed lesion obstructing 75% or greater of the lumen is generally required to cause symptomatic ischemia precipitated by exercise (most often manifested as chest pain, known as angina)
Obstruction of 90% of the lumen can lead to inadequate coronary blood flow even at rest.
This document discusses different types of angina and treatments. It describes 3 main types of angina: atherosclerotic angina which is caused by partially blocked arteries and accounts for 90% of cases; vasospastic angina which involves coronary artery spasms and can occur at rest; and unstable angina which is a medical emergency and precursor to heart attack. The major treatment strategies aim to increase oxygen delivery to the heart and reduce oxygen demand. Traditional pharmacological therapies discussed include nitrates, calcium channel blockers, and beta blockers which all work to relax blood vessels or reduce heart rate to improve oxygen supply. Newer drugs like ranolazine and ivabradine are also mentioned.
Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much blood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.
This document discusses gout and hyperuricemia. It defines gout as a type of inflammatory arthritis caused by uric acid crystals depositing in joints. Gout is associated with hyperuricemia, an elevated uric acid level. The document reviews risk factors, pathophysiology, clinical presentation, diagnosis, and treatment approaches including lifestyle changes, medications to treat acute attacks, and long-term urate-lowering therapy. It provides details on medications commonly used to treat gout such as allopurinol, febuxostat, colchicine, NSAIDs, and corticosteroids.
The document defines shock and describes its various types, including hypovolemic, cardiogenic, obstructive, and distributive shock. It discusses the pathophysiology, clinical presentation, diagnosis, and general treatment approach for shock. Regarding treatment, it emphasizes early correction of pulse, ventilation, oxygenation, and fluid administration. It then provides specific protocols for resuscitation in cases of hypovolemia and septic shock.
1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), results from blood clots forming in the veins. VTE is potentially fatal and is more likely to occur in immobilized patients, those with hypercoagulable disorders, or after trauma or surgery.
2) PE occurs when a clot breaks off and lodges in the lung arteries, partially or fully blocking blood flow. Patients with PE have a higher risk of recurrent VTE than those with DVT alone.
3) Treatment of VTE involves both prevention and acute phase treatment, with the goals of preventing PE/complications and reducing mortality and treatment side
This document discusses hyperlipidemia and dyslipidemia. It begins by defining hyperlipidemia and dyslipidemia as elevated blood levels of lipoproteins including cholesterol, triglycerides, and phospholipids. Abnormal lipoprotein levels increase the risk of coronary heart disease. The document then covers the pathophysiology of lipoprotein transport and metabolism. It describes the clinical presentation of hyperlipidemia, which is often asymptomatic initially. Diagnosis involves lipid profiling and classification of cholesterol and triglyceride levels. The focus of treatment is lowering LDL cholesterol through lifestyle changes and lipid-lowering drugs like statins when necessary.
This document provides information on osteoarthritis (OA), including its pathophysiology, risk factors, clinical presentation, diagnosis, and treatment approaches. It discusses how OA most commonly affects weight-bearing joints in older adults. The goals of treatment are outlined as relieving pain, maintaining mobility, and preserving joint integrity. First-line treatment involves non-pharmacological approaches like education, exercise, and weight loss, along with acetaminophen and topical or oral NSAIDs. For patients who do not respond to initial treatment, options include tramadol, duloxetine, intra-articular corticosteroids, and opioids. Treatment is tailored based on the specific joints affected, with topical therapies emphasized for hand
This document discusses cardiac arrhythmias, specifically atrial fibrillation and atrial flutter. It defines arrhythmias as irregularities in heart rhythm and describes their classification as bradyarrhythmias or tachyarrhythmias based on heart rate. For atrial fibrillation and flutter, it covers causes, diagnosis involving ECG findings, treatment goals of rate control and preventing stroke, and management strategies including medication use, cardioversion, and anticoagulation. It provides guidelines on acute treatment and long-term management based on left ventricular function.
Acute coronary syndromes (ACS) include unstable angina and myocardial infarction, which are forms of coronary heart disease caused by reduced blood flow due to plaque rupture and clot formation in the coronary arteries. The document discusses the epidemiology, risk factors, pathophysiology, clinical presentation, diagnosis, and treatment of ACS. It provides details on evaluating patients using biomarkers, ECG, risk scores, restoring blood flow through procedures like PCI or fibrinolysis, and employing antiplatelet and anticoagulant medications in the early treatment of ACS.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
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Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
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2. Introduction
Coronary heart disease (CHD) is the most common
type of heart disease and cause of heart attacks.
also known as atherosclerotic heart disease,
coronary artery disease (CAD), or
ischemic heart disease (IHD)
Coronary artery disease is the narrowing or blockage
of the coronary arteries,
usually caused by atherosclerosis.
2
3. ETIOLOGY
Angina pectoris.
Coronary atherosclerosis.
Coronary artery spasm.
Coronary artery embolism or thrombosis.
This can cause chest pain called angina.
3
6. PATHOPHYSIOLOGY….(2)
Progressive decrease in vessel radius associated with
coronary atherosclerosis impairs coronary blood flow
and causes angina pectoris
when myocardial oxygen demand ↑s, as with exertion.
Angina pectoris may occur because of
abrupt reduction in blood flow due to
• coronary thrombosis (unstable angina) or localized
vasospasm (variant or Prinzmetal angina)
• without increased oxygen demand.
6
7. Risk factors
Non-modifiable risk factors (those that cannot be
changed) include:
Male gender.
Advanced age.
Family history of heart disease
7
8. Risk factors…
Modifiable risk factors (you can treat or control) include:
Cigarette smoking and exposure to tobacco smoke
High blood cholesterol and high triglycerides
HTN (130/80 mm/Hg or higher)
Uncontrolled diabetes
Physical inactivity
Being overweight (BMI 25-29 or being obese (BMI >30
kg/m2)
Uncontrolled stress or anger
Diet high in saturated fat and cholesterol 8
9. Classification
IHD
Stable angina
Acute coronary syndrome
• Unstable angina
• non ST elevation MI
• ST elevation MI
9
10. Grading of Angina Pectoris by the Canadian
Cardiovascular Society Classification System
Class Description of Stage
Class I Ordinary physical activity does not cause angina, such as walking,
climbing stairs. Angina occurs with strenuous, rapid, or prolonged
exertion at work or recreation.
Class II Slight limitation or ordinary activity. Angina occurs on walking or
climbing stairs rapidly, walking uphill, walking or stair climbing after
meals, or in cold, or in wind, or under emotional stress, or only
during the few hours after wakening. Walking more than 2 blocks
on the level and climbing more than 1 flight of ordinary stairs at a
normal pace and in normal condition.
Class III Marked limitations of ordinary physical activity. Angina occurs on
walking 1 to 2 blocks on the level and climbing 1 flight of stairs in
normal conditions and at a normal pace.
Class IV Inability to carry on any physical activity without discomfort—
anginal symptoms may be present at rest.
10
11. Clinical Presentation
Symptoms
sensation of pressure/burning
over or near sternum; often but
not always radiating
• left jaw, shoulder, arm
chest tightness, shortness of
breath
visceral pain: lasts 0.5 to 30 min
precipitating factors: exercise,
cold environment, walking after a
meal, emotional upset, fright,
anger, coitus
relief with rest, nitroglycerin
11
Signs
abnormal precordial
systolic bulge
abnormal heart sounds
Typically no abnormal
laboratory tests
Likely to have abnormal
tests for IHD risk factors
History of chest pain
13. Desired Outcomes
Alleviate acute symptoms of myocardial ischemia
Reduce the number of ischemic episodes as well
as
increasing the amount of exertion or exercise a
patient can accomplish before inducing an
ischemic episode.
Slow the progression of atherosclerosis and
preventing complications of such as MI, HF,
stroke, & death.
Avoid or minimize adverse treatment effects.
13
14. General Treatment
Identification & treatment of aggravating
conditions
Anemia
Thyrotoxicosis
Aortic valve diseases
Obesity
Prevention & control of HTN, dyslipidemia, and
DM.
Avoidance of drugs that may be detrimental.
14
15. Treatment
General Approach to Treatment
The primary strategies for preventing ACS and death
are to:
Modify cardiovascular risk factors;
Slow the progression of coronary atherosclerosis;
and
Stabilize existing atherosclerotic plaques.
Non-pharmacologic therapy
15
16. Non-pharmacologic therapy
Surgical revascularization plays an important role in
the treatment of SIHD.
The most common revascularization procedures are
coronary artery bypass grafting (CABG) surgery or
percutaneous coronary intervention (PCI) with or
without stent placement
16
18. Drug therapy
Treatment Improve mortality in patients with SIHD by
providing guideline-directed medical therapy
(GDMT).
Anti-platelet agents
ACE inhibitors/ARBs
Statins
B-blockers
Calcium channel blockers
Nitrates
18
19. Antiplatelet Agents
platelets adhere to the site of atherosclerotic plaque rupture
activated,
Aggregated
stimulate thrombus formation and ACS.
o Guideline recommendations:
Aspirin 75–162 mg daily for all pnts, continued indefinitely in
the absence of contraindications, particularly in patients with
a Hx of MI.
Clopidogrel is a reasonable when aspirin is contraindicated.
Tt with aspirin (75–162 mg/d) and clopidogrel 75 mg/d might
be reasonable in certain high-risk patients with SIHD.
19
20. ACE Inhibitors
ACEIs have demonstrated the ability to:
stabilize coronary plaque,
provide restoration or improvement in endothelial
function,
inhibition of vascular smooth muscle cell growth,
↓ed macrophage migration, and
possibly possess some antioxidant activities.
20
21. Risk factor modification.
Lipid management: Statins
Guidelines recommend
All patients with known atherosclerotic CVD, such as SIHD,
should receive high-intensity statin therapy. High-intensity
statin options:
• Atorvastatin 40 or 80 mg (preferred dose) daily.
• Rosuvastatin 20 (preferred dose) or 40 mg daily.
Patients over the age of 75 years, or those who cannot
tolerate high-intensity statin, should receive moderate-
intensity statin.
• Moderate-intensity statin options:
• Atorvastatin 10–20 mg, Rosuvastatin 5–10 mg.
• Simvastatin 20–40 mg, Pravastatin 40 mg, Lovastatin 40
mg.
21
22. Risk factor modification….
Blood pressure management.
Drug selection in SIHD includes agents typically used to treat
other aspects of the disease.
• βBs, ACEIs & CCBs can be added if additional
therapy needed.
• Thiazide diuretics could also be an option.
Smoking cessation.
Nicotine replacement therapy.
Sustained release bupropion.
22
23. Treatment for Symptom relief.
βBs: Effective in reducing both symptomatic and silent
episodes of myocardial ischemia.
CCBs: Effective at reducing angina episodes, Reduction in
MVO2
Can be used safely in many patients with CIs to βB therapy.
Short-acting nitrates: First-line for acute attacks. NG SL 2–5
min prior to activities prevent predicted attacks.
Long-acting nitrates: Use is limited to tolerance.
Ranolazine.
Option for patients who cannot tolerate any of the traditional
agents due to hemodynamic or other adverse effects. 23
24. Short-acting nitrates.
Nitroglycerin to Relieve Acute Symptoms
Short-acting nitrates are first-line treatment to terminate
acute episodes of angina.
All patients with a history of angina should have sublingual
nitroglycerin tablets or spray to relieve acute ischemic
symptoms.
Nitrates
primarily cause venodilation reductions in preload
decrease in ventricular volume and wall tension
reduction in myocardial oxygen demand.
At higher doses, nitrates may also cause arterial dilation &
24
25. Long-Acting Nitrates (LANs)
Isosorbide dinitrate, in a sublingual form, has a longer half-
life with anti-anginal effects lasting up to 2 hours.
for patients with more frequent attacks, LANs is
recommended.
The major limitation of nitrate therapy is the development of
tolerance with continuous use.
Provide nitrate-free interval of 10–14 hrs per day or longer to
maintain efficacy.
25
26. Beta-Blockers
Stimulation of the β1-and β2- receptors in heart ↑ HR and
cardiac contractility.
βBs ↓ myocardial oxygen demand by
Antagonizing β1-and β2- Stimulation
Lowering BP and ventricular wall tension.
βBs may ↑ ventricular wall tension.
However, the net effect of β-blockade is usually a reduction in
myocardial oxygen demand
βBs with intrinsic sympathomimetic activity
produce lesser reductions in myocardial oxygen demand
and should be avoided in patients with IHD.
Other βBs appear equally effective at controlling symptoms of
26
27. Calcium Channel Blockers
Inhibition of calcium entry into the vascular smooth muscle
cells leads to systemic vasodilation and reductions in
afterload.
Inhibition of calcium entry into the cardiac cells leads to
reductions in cardiac contractility.
Reduction in wall tension
Reduction in myocardial oxygen demand
Nondihydropyridine CCBs further ↓ myocardial oxygen
demand.
Due to their negative chronotropic effects, verapamil &
diltiazem are generally more effective anti-anginal agents than
dihydropyridine CCBs.
27
28. Calcium Channel Blockers
CCBs are recommended as initial treatment in IHD when
βBs are contraindicated or not tolerated.
In addition, CCBs may be used in combination with βBs
when initial treatment is unsuccessful.
A long-acting dihydropyridine CCB is preferred.
Amlodipine and felodipine possess less negative inotropic
effects and appear to be safe in left ventricular systolic
dysfunction.
Finally, there is some evidence that short acting CCBs
(particularly short acting nifedipine & nicardipine) may ↑
risk of CV events. 28
29. Treatment: Special Considerations
Variable threshold angina and Prinzmetal’s
angina.
Nitrates & CCBs are effective agents for reducing
vasospasm.
Most patients respond well to SL NTG for acute
attacks.
Nifedipine, verapamil, & diltiazem are all equally
effective as single agents for initial management
of coronary vasospasm.
Dose titration is important to maximize the
29
31. Acute coronary syndromes
Unstable angina (UA)
Myocardial infarction (MI): Non-ST-Segment Elevation
MI (NSTEMI & UA), ST-Segment Elevation MI
(STEMI)
The cause of an acute coronary syndrome is
the rupture of an atherosclerotic plaque with
subsequent platelet adherence, activation, and
aggregation, and the activation of the clotting
cascade.
• Ultimately, a clot forms composed of fibrin and
platelets. 31
34. Unstable angina
Angina with at least one of the three features
• It occurs at rest, lasts >10 min
• Severe & of new onset, with in the past 4-6 wks.
NSTEMI
UA + elevated cardiac biomarkers
STEMI: NSTEMI + ST elevaiton
30 day mortality rate is 30 %, ½ of it occurs
before the patient reaches the hospital
34
35. Risk Stratification
35
TIMI Risk Score for NSTE-ACS
Risk of death, MI, or urgent need for revascularization as
follows: (One point for each of seven)
Age >65 years
>3 CHD risk factors: (smoking, hypercholesterolemia, HTN,
DM, Fx of premature CHD death/events)
Known CAD (50% or greater stenosis of at least one major
coronary artery on coronary angiogram)
Aspirin use within the past 7 days
Two or more episodes of chest discomfort within past 24
hours
ST-segment depression 0.5 mm or greater
Positive biochemical marker for infarction
TIMI Risk Score (5-7 points= High, 3-4 =Medium, 0-2= Low-
36. Acute Coronary Syndromes:
Treatment
DESIRED OUTCOMES
The short-term goals of Rx for ACS patient are as
follows:
Early restoration of blood flow to the infarct-related
artery to prevent infarct expansion (in case of MI) or
prevent complete occlusion and MI (in unstable
angina)
Prevention of death and other complications
Prevention of coronary artery reocclusion
Relief of ischemic chest discomfort
resolution of ST-segment and T-wave changes on the
ECG.
Long-term desired outcomes are
control of CV risk factors,
36
37. General approach….
STEMI,
• immediate primary PCI with balloon angioplasty or
stent placement is reperfusion treatment of choice
when patient presents within 12 hours of symptom
onset.
NSTE ACS at low risk:
Obtain serial biochemical markers.
High-risk NSTE ACS:
early coronary angiography (within 24 hours) &
revascularization if significant stenosis is found.
37
38. Early Pharmacotherapy for STE ACS
In Emergency department (ED):
Morphine PRN
Oxygen (if SO2<90)
sublingual ± IV NTG
DAT: (ASA+P2Y12Is)
Anticoagulant (UFH or enoxaparin/fondaparinux/
bivalirudin)
β-blocker (in ED, within first 24 h)
Fibrinolysis
38
40. Fibrinolytic Therapy
Administer within 30 min of arrival of STE ACS
patients if
Presenting to hospital within 12 hours of onset of chest
discomfort
and have at least 1 mm of STE .
Also consider in STE ACS patients
presenting within 12–24 hours of onset of chest discomfort
and have persistent symptoms of ischemia
and at least 1 mm of STE in two or more contiguous leads.
40
41. Thrombolytics
Drug Fibrin
Specificity
Dose
Streptokinase (SK)
(Streptase)
+ 1.5 MU in 50 mls NS/D5W IV over 60 mins
Tissue plasminogen
activator (tPA)
(Alteplase)
+++ IV Bolus: 15 mg, 0.75 mg/Kg over 30 mins
(max: 50mg), 0.5mg/Kg over 1 hr (max 35mg)
(max dose 100 mg)
Reteplase (rPA)
(Retevase)
++ 10 U IV push over 2 min, repeat after 30 min
Tenecteplase (TNK)
(TNKase)
++++ Single IV bolus given over 5 s based on weight
< 60Kg: 30 mg IV Bolus
60-70Kg: 35 mg IV Bolus
71-80Kg: 40 mg IV Bolus
81-90Kg: 45mg IV Bolus
> 91Kg: 50mg IV Bolus
41
alteplase, reteplase, & tenecteplase are acceptable as first-line agents.
42. Aspirin
Early aspirin administration to all patients without
contraindications within the first 24 hours of hospital
admission
In patients undergoing PCI, aspirin prevents acute
thrombotic occlusion during the procedure.
In patients experiencing ACS, an initial dose ≥160 mg
nonenteric aspirin is necessary to achieve rapid
platelet inhibition.
This first dose can be chewed in order to achieve high blood
concentrations and rapid platelet inhibition.
42
43. Thienopyridines.
Should be used as soon as possible concomitantly
with aspirin to prevent subacute stent thrombosis
and longer term CV events.
Recommended duration is 12 months following
PCI for STEMI receiving a bare metal stent or
drug-eluting stent.
Clopidogrel
43
44. Glycoprotein (GP) IIb/IIIa receptor
inhibitors.
Do not give GPIs to STEMI patients who will not undergo
PCI.
If UFH is selected for primary PCI in STEMI, add GPIs
to UFH (in addition to a thienopyridine and aspirin)
to reduce likelihood of reinfarction for patients not given
fibrinolytics.
Abciximab 0.25 mg/kg IV bolus given 10–60 min before
start of PCI, followed by 0.125 mcg/kg/min (maximum 10
mcg/min) for 12 hours.
Eptifibatide 180 mcg/kg IV bolus, repeated in 10 min,
followed by infusion of 2 mcg/kg/min for 18–24 hours after
PCI.
Tirofiban 25 mcg/kg IV bolus, followed by an infusion of
44
45. Anticoagulants
Patients undergoing primary PCI
UFH or bivalirudin is preferred;
In fibrinolysis,
UFH, enoxaparin, or fondaparinux may be
administered.
45
46. Anticoagulants….UFH dosing
UFH dose for primary PCI:
50–70 units/kg IV bolus if GPI is planned and 70–
100 units/kg IV bolus if no GPI is planned;
give supplemental IV bolus doses to maintain the
target activated clotting time (ACT).
UFH dose for STEMI with fibrinolytics:
60 units/kg IV bolus (max 4000 units), followed by
continuous infusion of 12 units/kg/h (max. 1000
units/h).
Adjust to maintain target aPTT 1.5–2 times control
(50–70 s). 46
47. Dosing…for others
Enoxaparin dose for STEMI:
1 mg/kg SC Q 12–24 hours depending on renal function.
For STEMI patients receiving fibrinolytics, enoxaparin 30 mg
IV bolus is followed immediately by 1 mg/kg SC Q12h if < 75
years (0.75 mg/kg SC Q12h if ≥75 years).
Bivalirudin dose for PCI in STEMI:
0.75 mg/kg IV bolus then 1.75 mg/kg/h continuous infusion.
Discontinue at end of PCI or continue at 0.25 mg/kg/h if
prolonged anticoagulation is necessary.
Fondaparinux dose for STEMI:
2.5 mg IV bolus, followed by 2.5 mg SC daily starting on
hospital day 2. 47
48. Nitrates
One SL NTG tablet (0.4 mg) should be administered
every 5 minutes for up to three doses to relieve
myocardial ischemia.
ACEIs or βBs, should not be withheld for nitrates use
because the mortality benefit of nitrates is unproven.
IV NTG initiated in all ACS with persistent ischemia,
HF, or uncontrolled high BP in the absence of CIs.
IV NTG continued for approximately 24 h after ischemia
relieved
The most significant adverse effects of nitrates are
tachycardia, flushing, headache, and hypotension.
Nitrate CI with oral PDE-5 inhibitors, such as sildenafil
48
49. β-Blockers
A βB should be administered early in the care of
patients with STE ACS and continued indefinitely.
Early administration of a βB within the first 24 hours
of hospitalization in patients lacking a
contraindication is a quality care indicator.
49
50. BB…
Target resting HR is 50–60 beats/min; initial IV
therapy may be omitted, if appropriate.
Metoprolol 5 mg by slow (over 1–2 min) IV bolus,
repeated Q 5 min for a total initial dose of 15 mg;
follow in 1–2 hours by 25–50 mg orally every 6 hours.
Propranolol 0.5–1 mg slow IV push, followed in 1–2
hours by 40–80 mg PO every 6–8 hours.
Atenolol 5 mg IV dose, followed 5 min later by a
second 5 mg IV dose, then 50–100 mg PO daily
beginning 1–2 h after the IV dose.
For at least 3 years for normal EF, indefinitely if
50
51. Calcium Channel Blockers
Administration of CCBs in the setting of STE ACS is
reserved for patients who have contraindications to
βBs and is given for relief of ischemic symptoms.
In patients prescribed CCBs for treatment of
hypertension who are not receiving βBs and who do
not have a contraindication to βBs, the CCB should be
discontinued and a βB initiated.
Nifedipine should be avoided because it has
demonstrated reflex sympathetic activation,
tachycardia, and worsened myocardial ischemia. 51
52. Early pharmacotherapy for NSTE-
ACS
Generally similar to that of STEMI
all patients with NSTE-ACS should be tted in the ED
with
Morphine PRN in refractory patients
IN Oxygen (if O2 saturation <90)
sublingual ± IV NTG (IV in selected patients )
DAT (Aspirin with P2y12 inhibitors)
Anticoagulant (UFH or enoxaparin/fondaparinux/bivalirudin)
PO β-blocker (in ED, within first 24 h) (IV in selected pnts)
High-risk patients should proceed to early angiography and
may receive a GPI (optional with either UFH
or enoxaparin but should be avoided with bivalirudin). 52
54. Fibrinolytic Therapy
is not indicated in any patient with NSTE-ACS
because increased mortality has been reported with
fibrinolytics compared with controls in clinical trials in
(patients with normal or ST-segment depression
ECGs).3
54
55. Aspirin
Reduces the risk of death or developing MI by about
50% (compared with no antiplatelet therapy) in
patients with NSTE-ACS.
Therefore, aspirin remains the cornerstone of early
treatment for all patients with ACS.
Dosing of aspirin for NSTE-ACS is the same as that
for STEMI.
55
56. Anticoagulants
UFH 60 units/kg IV bolus (max. 4000 units), followed
by a continuous IV infusion of 12 units/kg/h (max.
1000 units/h); titrate to maintain aPTT between 1.5
and 2 times control.
Duration: continued for
up to at least 48 hours for UFH,
until the patient is discharged from the hospital (or 8
days, whichever is shorter) for either enoxaparin or
fondaparinux, or
until the end of PCI or angiography procedure (or
up to 72 hours following PCI for bivalirudin). 56
57. Nitrates
Similar indication and dose recommendation to STE
ACS
BBs
Recommendations are similar to STE ACS
Calcium Channel Blockers
Should not be administered to most patients.
Agent selection and indication for NSTE-ACS is
identical to STEMI
57
58. SECONDARY PREVENTION FOLLOWING
MI
The long-term goals following MI are as follow:
1. Control modifiable CHD risk factors
2. Prevent development of systolic heart failure
3. Prevent recurrent MI and stroke
4. Prevent death, including sudden cardiac death
58
59. Late hospital care/secondary prevention
agents for both types of MI
59
All patients (ABAS)
1. Antiplatelet (ASA indefinitely +P2Y12 inhibitors ≥ 12
months)
2. BBs (within 24 hours of ED visit) indefinitely if no CI
3. ACEIs/ARBs
4. Statins (high-intensity)
5. NTG PRN
On selected pnts
1. Aldosterone antagonists
2. Clopidogrel
3. warfarin
60. Anticoagulants
Warfarin should be considered in selected patients
following an ACS,
patients with an LV thrombus,
patients demonstrating extensive ventricular wall-
motion abnormalities on cardiac echocardiogram,
and
patients with a history of thromboembolic disease or
chronic atrial fibrillation.
60
61. EVALUATION OF THERAPEUTIC
OUTCOMES
Monitoring parameters for efficacy of therapy
include:
relief of ischemic discomfort;
return of ECG changes to baseline; and
absence or resolution of heart failure signs.
61
Editor's Notes
CONDITION/DISORDER SYNONYMS
Angina pectoris.
Coronary artery disease.
DEFINITION
Lack of oxygen and decreased or no blood flow to myocardium resulting from coronary artery narrowing or obstruction.
Race. African Americans have more severe high BP than Caucasians and therefore have a higher risk of heart disease. Heart disease risk is also higher among Mexican Americans, American Indians, and some Asian Americans. This is partly due to higher rates of obesity and diabetes in these populations.
Response to nitroglycerin or rest.
Cardiac enzymes
are normal in stable angina;
troponin T or I, myoglobin, and creatinine kinase myocardial band (CK-MB) may be elevated in unstable angina
Prevent acute coronary syndromes and death;
Alleviate acute symptoms of myocardial ischemia
Prevent recurrent symptoms of myocardial ischemia; and
Avoid or minimize adverse treatment effects.
Door-to-balloon time is a phrase that denotes the time between the arrival of a patient with STEMI in the emergency room until the time that a balloon is inflated in the occluded, culprit coronary artery.
ACC/AHA for the use of antiplatelet agents in the management of SIHD include a Class I recommendation for the use of aspirin 75 to 162 mg daily. 1 Aspirin should be continued indefinitely in the absence of contraindications (LOE A). Clopidogrel is considered an appropriate alternative when aspirin is contraindicated (LOE B). The guidelines state that treatment with aspirin (75-162 mg daily) and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD (Class IIb, LOE B recommendation).
ecommendations from the ACC/AHA include a Class I recommendation to use ACE inhibitors in all patients with SIHD who also have HTN, DM, HFrEF, or chronic kidney disease, unless contraindicated (LOE A). 1 ARBs are recommended for the same patient populations if they are intolerant to ACE inhibitors (LOE A). It is a Class IIa recommendation to use ACE inhibitors in patients with both SIHD and other vascular diseases (LOE B), and ARBs in these patients if intolerant to ACE inhibitors (LOE B).
regimens. 47 Current guidelines recommend that all patients with known ASCVD, such as SIHD, should receive high-intensity statin therapy to achieve a 50% or more reduction in LDL-C. 48 Patients over the age of 75 years, or those who cannot tolerate high-intensity statin therapy, should receive moderate-intensity statin therapy to achieve a 30% to 50% reduction in LDL-C. In patients with clinical ASCVD who do not achieve a 50% reduction in LDL-C or who have an LDL ≥100 mg/dL (2.59 mmol/L) on high-intensity statin therapy, the additional nonstatin therapies such as ezetimibe, bile-acid sequestrates, or PCSK9-inhibitors may be considered
Drugs used to treat HTN in patients with SIHD commonly include agents that can be used to treat the symptoms of the disease. β-blockers are often used to control angina symptoms and they also lower BP. Patients may also be on ACE inhibitors to reduce CV risk.
Like HTN, the glycemic target for patients with DM, including those with SIHD, is the subject of considerable debate. Studies have found that achieving an A1c of less than 7% (53 mmol/mol Hgb) reduces microvascular complications from DM such as retinopathy, nephropathy, and neuropathy.
Metformin is the drug of first choice for the treatment of DM type 2, including patients with SIHD.
. All patients with CAD should have access to SL NTG tablets or spray for the treatment of acute episodes of angina.
Provide some ↑ in supply by inducing coronary vasodilation & preventing vasospasm.
ACS is classified according to electrocardiogram (ECG) changes into STEMI or NSTE-ACS (NSTEMI and UA) (Fig. 17-1).3 A STEMI occurs when symptoms of myocardial ischemia occur in conjunction with new STE with subsequent release of biomarkers of myocardial necrosis, mainly troponins T or I.2 Image not available. A STEMI typically results in an injury that transects the thickness of the myocardial wall. Following a STEMI, pathologic Q waves are frequently seen on the ECG, indicating transmural MI, whereas such an ECG manifestation is seen less commonly in patients with NSTEMI.3 NSTEMI is limited to the subendocardial myocardium and is not as extensive as STEMI. NSTEMI differs from UA in that ischemia is severe enough to produce myocardial necrosis resulting in the release of a detectable amount of troponins T or I, from the necrotic myocytes in the bloodstream.
NSTEMI differs from UA in that ischemia is severe enough to produce myocardial necrosis resulting in the release of a detectable amount of troponins T or I, from the necrotic myocytes in the bloodstream.
Patients with STEMI are of the highest priority and should be emergently referred to the cardiac catheterization lab for primary PCI
Patients with NSTE-ACS will undergo additional risk stratification to determine the best approach, which is usually an early invasive approach (eg, PCI) for intermediate- and high-risk patients or a more conservative, ischemia-guided management plan without planned PCI for those with either the lowest risk for coronary event or contraindications to the invasive procedure itself
Regardless of treatment strategy planned (early invasive approach or ischemia-guided approach), general treatment measures for intermediate- and high-risk patients include admission to the hospital, oxygen administration, antithrombotic t/t initiated
Short-term desired outcomes in a patient with ACS are: (a) early restoration of blood flow to the infarct-related artery to prevent infarct expansion (in the case of MI) or prevent complete occlusion and MI (in UA); (b) prevention of death and other MI complications; (c) prevention of coronary artery reocclusion; and as evidence of restoration of coronary artery blood flow; (d) relief of ischemic chest discomfort; and (e) resolution of ST-segment and T-wave changes on the ECG.
Long-term desired outcomes are control of CV risk factors, prevention of additional CV events, including reinfarction, stroke, and HF, and improvement in quality of life.
Selecting evidence-based therapies for patients without contraindications results in lower mortality.17,18
General treatment measures for all STEMI and high- and intermediate-risk NSTE-ACS patients include admission to hospital, oxygen administration (if oxygen saturation is low, less than 90%), continuous multi-lead ST-segment monitoring for arrhythmias and ischemia, frequent measurement of vital signs, bed rest for 12 hours in hemodynamically stable patients, avoidance of the Valsalva maneuver (prescribe stool softeners routinely), and pain relief
aOptions after coronary angiography also include medical management alone or CABG surgery. bClopidogrel preferred P2Y12 inhibitor when fibrinolytic therapy is utilized in DAT. No loading dose recommended if age older than 75 years. cGiven for up to 48 hours or until revascularization-SC UFH. dSC enoxaparin/fondaparinux: Given for the duration of hospitalization, up to 8 days or until revascularization. eIf pretreated with UFH, stop UFH infusion for 30 min prior to administration of bivalirudin (bolus plus infusion). fIn patients with STEMI receiving a fibrinolytic or who do not receive reperfusion therapy, administer clopidogrel for at least 14 days and ideally up to 1 year. (CI, contraindication; FMC, first medical contact; GPI, glycoprotein IIb/IIIa inhibitor)
The mortality benefit of fibrinolysis is highest with early administration and diminishes after 12 hours.2 The use of fibrinolytics between 12 and 24 hours after symptom onset should be limited to patients with ongoing ischemia.
Given within 30 min of arrival for patients presenting within 12 hours of onset of chest discomfort to a hospital not capable of primary PCI and cannot be transferred and undergo PCI within 120 min of medical contact. Also consider for patients with persistent ischemic symptoms who present within 12 to 24 hours of symptom onset.
Consult product information for list of absolute and relative contraindications.
although the risk of major bleeding, particularly gastrointestinal bleeding, appears to be reduced by using lower doses of aspirin,
low-dose aspirin, taken chronically, is not free of adverse effects.
Patients should be counseled on the potential risk of bleeding.
Aspirin therapy should be continued indefinitely
Clopidogrel.
For patients with aspirin allergy,
use 300–600 mg loading on day 1, followed by 75 mg/day, continued indefinitely.
For patients treated with fibrinolytics and in those receiving no revascularization,
use 75 mg or 300 mg on day 1 followed by 75 mg/day for up to 1 year plus aspirin 75–325 mg once daily.
For patients undergoing primary PCI,
Use 300–600 mg loading followed by 75 mg/day plus aspirin 81 mg once daily.
UFH, administered as an IV bolus followed by a continuous infusion, is a first-line anticoagulant for treatment of patients with STE ACS,
both for medical therapy and for patients undergoing PCI.
Anticoagulant therapy should be initiated in the emergency department and continued for at least 48 hours in selected patients who will be bridged over to receive chronic warfarin anticoagulation following acute MI
If a patient undergoes PCI, UFH is discontinued immediately after the procedure.
UFH, administered as an IV bolus followed by a continuous infusion, is a first-line anticoagulant for treatment of patients with STE ACS,
both for medical therapy and for patients undergoing PCI.
Anticoagulant therapy should be initiated in the emergency department and continued for at least 48 hours in selected patients who will be bridged over to receive chronic warfarin anticoagulation following acute MI
If a patient undergoes PCI, UFH is discontinued immediately after the procedure.
Nitrates promote the release of nitric oxide from the endothelium, which results in venous and arterial vasodilation at higher doses.
Venodilation lowers preload and myocardial oxygen demand.
Arterial vasodilation relieves coronary artery vasospasm, dilating coronary arteries to improve myocardial blood flow and oxygenation.
non-DHP CCBs (eg, diltiazem, verapamil) to treat angina symptoms in patients with ACS who have a contraindication, have intolerance, or are refractory to β-blockers in the absence of left ventricular dysfunction, risk factors for cardiogenic shock, and atrioventricular conduction defects
Similar to STE ACS treatment with a few exceptions
fibrinolytic therapy contraindicated
GP IIb/IIIa receptor blockers (abciximab, eptifibatide) administered to high-risk patients undergoing invasive method, like coronary angiography
Morphine is administered to patients with refractory angina as an analgesic and a venodilator that lowers preload.
These agents should be administered early, while the patient is still in the emergency department.
Analgesia and anti-emetics
The pain of myocardial infarction is usually severe and requires potent opiate analgesia. Intravenous diamorphine 2.5–5 mg (repeated as necessary) is the drug of choice and is not only a powerful analgesic but also has a useful anxiolytic effect. The use of opiates may be associated with nausea and vomiting which can be prevented with anti-emetic drugs such as cyclizine 50 mg or metoclopramide 10 mg given intravenously. Opiate analgesia may also be associated with arterial hypoxaemia (see above). For some patients the psychological stress of a coronary event and the environment of a coronary care unit can provoke severe anxiety; the use of diazepam 2–5 mg orally as an anxiolytic and hypnotic may be useful.
SL NTG followed by IV NTG for patients with persistent ischemia, HF symptoms, or uncontrolled HTN;
continue IV NTG for about 24 hours after ischemia relief.
Dose similar to STE ACS
BBs
Recommendations are similar to STE ACS
In absence of CIs, initiate oral βBs within 24 hours of admission to all patients and continue indefinitely.
Consider IV βBs for hemodynamically stable patients who present with persistent ischemia, HTN, or tachycardia.
βBs are continued indefinitely in patients with LVEF < 40% (0.40) & for at least 3 years in normal LV function.
Calcium Channel Blockers
Should not be administered to most patients.
Second-line tt for CIs to βBs and those with continued ischemia despite βB and nitrate therapy.
Agent selection for NSTE-ACS is identical to STEMI
either diltiazem or verapamil preferred unless LV systolic dysfunction, bradycardia, or heart block, and then either amlodipine or felodipine is preferred.
Immediate-release nifedipine is contraindicated, especially in the absence of a βB.
All patients at discharge:
ASA/clopidogrel
β-blocker
Statins /high intensity/
ACE inhibitor or ARB
NTG