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DISEASE
Definition
• " Ischaemia " refers to an insufficient amount of blood. The
coronary arteries are the only source of blood for the heart muscle.
If this coronary arteries are blocked, the blood supply will reduce.
Physiology of coronary circulation
• Heart is supplied by two major coronary arteries,
originating from the aortic root
Needs Supply
• Systolic BP • Diameter of coronary artery
• Heart rate • Blood O2 capacity – Hb
• Myocardial contractility and thickness concentration, oxygen concentration
• Myocardial wall stress
Main features of stable ischemic heart disease
DIAGNOSIS
Historical description of angina
This is a disorder of the breast, marked with strong and peculiar symptoms,
considerable for the kind of danger belonging to it . . . .The seat of it, and sense of
strangling and anxiety with which it is attended, may make it not improperly called
angina pectoris . . . .Those who are afflicted with it are seized . . . with a painful
and most disagreeable sensation in the breast, which seems as if it would take
their life away, if it were to increase or continue . . . . When a fit of this sort comes
on by walking, its duration is very short, as it goes off almost immediately upon
stopping. If it comes on in the night, it will last an hour or two.
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Location and radiation of anginal pain
Chest pain (angina)
Clinical classification of chest pain
• Weak relationship between severity of pain and degree of oxygen supply-
there can be severe pain with minimal disruption of oxygen supply or no pain
in severe cases
• Four types:
Stable angina
Unstable angina
Microvascular angina
Prinzmetal’s angina
Stable angina
• Cause unknown
• Possible mechanisms
• endothelial dysfunction
• microvascular ischemia
• abnormal pain perception
• Angina, positive stress test, normal coronary arteries (at angiography)
• Good prognosis
Prinzmetal’s (variant) angina
Echocardiography
Exclusion of alternative causes of angina
Identification of regional wall motion abnormalities
Measurement of LV ejection fraction
Evaluation of diastolic function
Laboratory
• cardiac enzymes – troponin, CK-MB
• hemoglobin, hematocrit, WBC, platelets
• lipid profile – cholesterol, triglycerides, HDL-cholesterol, LDL-
cholesterol
• glycemia
• creatinine
Clinical pretest probability in patients with
chest pain
Stress testing
• Methods to induce ischemia
• exercise
• pharmacological – dobutamine, adenosine, dypiridamole
• Single-vessel disease
• Two-vessel disease
• Multi-vessel disease
• Left main disease
Stable angina management
General measures
• Smoking cessation
• Weight loss, diet and physical activity
• Control of blood pressure and diabetes
Pharmacological treatment of stable angina
• Secondary causes
• increased demand – tachycardia, severe hypertension, cocaine use, hyperthyroidism,
fever
• decreased supply – anemia, hypoxemia
Historical definition
Fowler 1971
Classification
Diagnosis
• Angina
• at rest/minimal exertion
• recent onset/increased severity
• more severe and protracted – requires several doses of NTG or prolonged rest
• ECG changes
• ST depression > 0.5 mm
• T wave inversion
• new BBB
• ST elevation in aVR – possible left main stenosis or multivessel disease
• Normal serial cardiac enzymes (troponin, CK-MB)
• NSTEMI – increased cardiac enzymes
• Coronary angiography – indicated in all patients
TREATMENT
Antiplatelets – mechanism of action
Antiplatelets
• Aspirin – 150-300 mg chewed, followed by 75 – 100 mg daily
+
• Clopidogrel – loading dose 300-600 mg, followed by 75 mg/day, or
• Ticagrelor – loading dose 180 mg, followed by 2x90 mg/day, or
• Prasugrel – loading dose 60 mg, followed by 10 mg/day
• Heparin (unfractionated)
• iv bolus 4000 u, followed by infusion 1000 u/h or 4000 u iv every 4 h
• monitoring for dosage adjustment – aPTT
• side effects – bleeding, thrombocytopenia
• Low molecular weight heparins (LMWH)
• Enoxaparin 1 mg/kg sc every 12 h
• Fondaparinux 2,5 mg sc once daily
• no monitoring is necessary
• Duration of therapy = 5-7 days
Antiischemic, secondary prevention
• Nitrates
• Nitroglyerin –
• sublingual up to 3 consecutive tablets
• iv infusion 10 – 100 µg/min
• Betablockers
• Calcium channel blockers
• ACE inhibitors
• High dose statins
• Atorvastatin 80 mg, Rosuvastatin 40 mg
Revascularization
• PCI + stenting (drug eluting stents, bare metal stents)
• CABG