Cad

1. Dr Shubham Upadhyay
© Medi - Lectures Dr Shubham Upadhyay 1

2. PATHOPHYSIOLOGY
© Medi - Lectures Dr Shubham Upadhyay 2
• Imbalance between supply & demand due to thrombus formation:
1. Plaque rupture, erosion or a calcified protruding nodule
2. Coronary artery vasoconstriction
3. Gradual intraluminal narrowing
4. Hyperdynamic states with fixed epicardial coronary obstruction
15%
NSTE-ACS-->Angiography
35%
20%
20%
10%

3. HISTORY & PHYSICAL EXAMINATION
© Medi - Lectures Dr Shubham Upadhyay 3
• Severe chest discomfort with one of the three features-
1. At rest (or with minimal exertion), lasting >10 min
2. Relatively recent onset ( within 2 weeks)
3. Crescendo pattern
• Physical Examination similar to stable angina
- If large myocardial ischemia or large NSTEMI, diaphoresis, pale cool
skin, sinus tachycardia, S3 S4, basilar rales and hypotension

4. INVESTIGATIONS
© Medi - Lectures Dr Shubham Upadhyay 4
• ECG- ST segment depression
T wave inversion
• Cardiac Biomarkers
-Trop I or T
-CK-MB
• Stress Testing

5. INVESTIGATIONS
© Medi - Lectures Dr Shubham Upadhyay 5
• ECG- ST segment depression
T wave inversion
• Cardiac Biomarkers
-Trop I or T
-CK-MB
• Stress Testing
Causes of Elevation of Troponin other
than MI
Cardiac Non Cardiac
• Tachyarrhythmias
• CHF
• HTNsive Emergencies
• Infection/Inflammatio
n eg Myocarditis,
Pericarditis
• Stress
Cardiomyopathy
• Structural Heart
Disease eg AS
• Aortic Dissection
• Coronary Spasm
• Cardiac Procedures
• Infiltrative Diseases eg
Amyloidoses,
Malignancy
• Pulm. Emolism, PHTN
• Trauma
• Hypo or
Hyperthyroidism
• Toxicity
• Renal Failure
• Sepsis, Shock
• Stroke & other acute
neurological
conditions
• Extreme exercise
• Rhabdomyolysis

6. INVESTIGATIONS
© Medi - Lectures Dr Shubham Upadhyay 6
• ECG- ST segment depression
T wave inversion
• Cardiac Biomarkers
-Trop I or T
-CK-MB
• Stress Testing
• Goals
1. Recognize/Exclude MI using
biomarkers (Trop)
2. Detect rest ischemia (using
serial or continuous ecg)
3. Detect coronary obstruction at
rest with CCTA and ischemia
with stress testing

7. TREATMENT
© Medi - Lectures Dr Shubham Upadhyay 7

8. TREATMENT- ANTI ISCHEMIC DRUGS
© Medi - Lectures Dr Shubham Upadhyay 8
DRUG
CLASS
CONDITION WHEN TO AVOID DOSE
Nitrates ACS with chest
discomfort or an anginal
equivalent
-Hypotension
-Right ventricular infarction
-Severe AS
-Patient recieving PDE5 inhibitor
• Initial S/L or buccal ->I/V
• i/v- 5-10 mcg/min infusion upto 100
mcg/min till relief of symptoms or
limiting s/e

9. TREATMENT- ANTI ISCHEMIC DRUGS
© Medi - Lectures Dr Shubham Upadhyay 9
DRUG
CLASS
CONDITION WHEN TO AVOID DOSE
Nitrates ACS with chest
discomfort or an anginal
equivalent
-Hypotension
-Right ventricular infarction
-Severe AS
-Patient recieving PDE5 inhibitor
• Initial S/L or buccal ->I/V
• i/v- 5-10 mcg/min infusion upto 100
mcg/min till relief of symptoms or
limiting s/e
Beta
Blockers
All patients with ACS -PR interval >0.24 sec
-2° or 3° atrioventricular block-
-Heart rate <50 beats/min
-Systolic pressure <90 mmHg
-Shock
-Left ventricular failure
-Severe reactive airway disease
• Metoprolol 25–50 mg by mouth every 6
hr
• If needed, and no heart failure, 5-mg
increments by slow (over 1–2 min) IV
administration

10. TREATMENT- ANTI ISCHEMIC DRUGS
© Medi - Lectures Dr Shubham Upadhyay 10
DRUG
CLASS
CONDITION WHEN TO AVOID DOSE
Nitrates ACS with chest
discomfort or an anginal
equivalent
-Hypotension
-Right ventricular infarction
-Severe AS
-Patient recieving PDE5 inhibitor
• Initial S/L or buccal ->I/V
• i/v- 5-10 mcg/min infusion upto 100
mcg/min till relief of symptoms or
limiting s/e
Beta
Blockers
All patients with ACS -PR interval >0.24 sec
-2° or 3° atrioventricular block-
-Heart rate <50 beats/min
-Systolic pressure <90 mmHg
-Shock
-Left ventricular failure
-Severe reactive airway disease
• Metoprolol 25–50 mg by mouth every 6
hr
• If needed, and no heart failure, 5-mg
increments by slow (over 1–2 min) IV
administration
CCB -No relief by adequate
dose of nitrates and beta
blockers
-Unable to tolerate
doses
-Variant angina
-Pulmonary Edema
-Evidence of LV dysfunction (for Non DHP)

11. TREATMENT- ANTI ISCHEMIC DRUGS
DRUG
CLASS
CONDITION WHEN TO AVOID DOSE
Nitrates ACS with chest
discomfort or an anginal
equivalent
-Hypotension
-Right ventricular infarction
-Severe AS
-Patient recieving PDE5 inhibitor
• Initial S/L or buccal ->I/V
• i/v- 5-10 mcg/min infusion upto 100
mcg/min till relief of symptoms or
limiting s/e
Beta
Blockers
All patients with ACS -PR interval >0.24 sec
-2° or 3° atrioventricular block-
-Heart rate <50 beats/min
-Systolic pressure <90 mmHg
-Shock
-Left ventricular failure
-Severe reactive airway disease
• Metoprolol 25–50 mg by mouth every 6
hr
• If needed, and no heart failure, 5-mg
increments by slow (over 1–2 min) IV
administration
CCB -No relief by adequate
dose of nitrates and beta
blockers
-Unable to tolerate
doses
-Variant angina
-Pulmonary Edema
-Evidence of LV dysfunction (for Non DHP)
Morphine
sulfate
No relief on 3 doses of
NTG, recurrence
Hypotensi©onM,edRie
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Confusion, Obtundation
2-5 mg iv 11
can be repeated every 5-30 min

12. TREATMENT- ANTI PLATELET DRUGS
COX INHIBITOR
• ASPIRIN (COX
INHIBITOR)
-DOSE
Initial- 325 mg non enteric
formulation
Thereafter- 75 mg/day
enteric or non enteric
-C/I- severe active bleeding,
Aspirin allergy
12
© Medi - Lectures Dr Shubham Upadhyay

13. TREATMENT- ANTI PLATELET DRUGS
13
COX INHIBITOR P2Y12 INHIBITOR
• ASPIRIN (COX
INHIBITOR)
-DOSE
Initial- 325 mg non enteric
formulation
Thereafter- 75 mg/day
enteric or non enteric
-C/I- severe active bleeding,
Aspirin allergy
P2Y12 Inhibitor (inhibits platelet activation)
• Clopidogrel (prodrug)- Irreversible blockade
- Loading- 300 to 600 mg
-Maintenance- 75 mg daily
-DAPT
• Prasugrel - Thienopyridine
- Rapid and higher level platelet inactivation
-Adjunct to PCI
-Loading 60 mg
-Maintenance- 10 mg daily
-C/i- prior stroke, TIA, high risk of bleeding
• Ticagrelor - Reversible P2Y12 blockade
-better than Clopidogrel
-Loading- 180 mg
-Maintenance- 90 mg BD
• Cangrelor- i/v direct, rapid acting , P2Y12
inhibitor
-30mcg/kg bolus f/b 4 mcg/kg/min infusion
-Adjunct to PCI © Medi - Lectures Dr Shubham Upadhyay

14. TREATMENT- ANTI PLATELET DRUGS
COX INHIBITOR P2Y12 INHIBITOR GPIIB/IIIA INHIBITORS
• ASPIRIN (COX
INHIBITOR)
-DOSE
Initial- 325 mg non enteric
formulation
Thereafter- 75 mg/day
enteric or non enteric
-C/I- severe active bleeding,
Aspirin allergy
P2Y12 Inhibitor (inhibits platelet activation)
• Clopidogrel (prodrug)- Irreversible blockade
- Loading- 300 to 600 mg
-Maintenance- 75 mg daily
-DAPT
• Prasugrel - Thienopyridine
- Rapid and higher level platelet inactivation
-Adjunct to PCI
-Loading 60 mg
-Maintenance- 10 mg daily
-C/i- prior stroke, TIA, high risk of bleeding
• Ticagrelor - Reversible P2Y12 blockade
-better than Clopidogrel
-Loading- 180 mg
-Maintenance- 90 mg BD
• Cangrelor- i/v direct, rapid acting , P2Y12
inhibitor
-30mcg/kg bolus f/b 4 mcg/kg/min infusion
-Adjunct to PCI © Medi - Lectures Dr Shubham Upadhyay
• Addition to DAPT makes it Triple
Antiplatelet Therapy
• Reserved for unstable patients (recurrent
chest pain, elevated Trop, ECG changes,
coronary thrombus on angio) undergoing
PCI
• Intravenous drugs
• Abciximab
-0.25 mg/kg bolus f/b 0.125 mcg/kg/min for
upto 1 day
• Eptifibatide
• Tirofiban
-25 mcg/kg/min f/b 0.15 mcg/kg/min for 2-
4 days
14

15. ANTICOAGULANTS
© Medi - Lectures Dr Shubham Upadhyay 15
UNFRACTIONATED
HEPARIN(UFH)
• Bolus 70-100 U/kg (max 5000 U) iv f/b infusion of 12-15 U/kg per Hr
LOW MOLECULAR WEIGHT
HEPARIN (LMWH)
• Enoxaparin
• Superior to UFH
• But increased risk of bleeding as compared to UFH
• I/V bolus 30 mg
• Then 1 mg/kg s/c every 12 hr
• Renal adjustment - If CrCl <30 ml/min- 1mg/kg OD
BIVALIRUDIN •IV bolus 0.75 mg.kg
Infusion of 1.75 mg/kg/Hr
• Less bleeding risk
FONDAPARINUX • 2.5 mg s/c OD
• Equivalent to Enoxaparin but lower risk of bleeding

16. INVASIVE vs CONSERVATIVE STRATEGY
© Medi - Lectures Dr Shubham Upadhyay 16
INVASIVE STRATEGY CONSERVATIVE STARTEGY
Initiation of Medical treatment
Arteriography within 48 hr of presentation f/b
revascularization (PCI)
High risk patients (multiple risk factors, ST segment
deviation, positive biomarkers)
Initiation of Medical treatment
Close observation , serial ECGS
Arteriography if rest pain, ST changes, Biomarker
positive

17. LONG TERM MANAGEMENT
© Medi - Lectures Dr Shubham Upadhyay 17
• Risk factor modification
• Beta Blockers
• Statins
• Ezetimibe
• ACE inhibitors/ARBs
• Antiplatelets

18. PRINZMETAL’S VARIANT ANGINA
© Medi - Lectures Dr Shubham Upadhyay 18
• Severe ischemic pain at rest
• Transient ST elevation
• Focal spasm of epicardial Coronary artery resulting in transient intramural ischemia and
abnormalities of LVf function
• Can lead to Acute MI, VT, VF, sudden cardiac death
• Hypercontractility of vasc. sm. ms. (in response to adr. vasoconstrictors, LT, or Serotonin)
• C/F
ECG
Angiography
• Treatment
Nitrates and CCBs
Statins
Coronary Revascularization

19. © Medi - Lectures Dr Shubham Upadhyay 19

20. © Medi - Lectures Dr Shubham Upadhyay 20