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Patient Presentation Beebee Meeajun Demographics: Mr PG 63 years old Caucasian Presenting Complaint: Tingling in chest History of presenting complaint: Admitted via A&E on 2/9/03 Paraesthesiae Symptoms from previous 5 days Cold weather No pain/SOB/palpitations/nausea GTN Episodes last up half hour 1st experience Tests Past History: Hypertension Blood clot in eye TB 40 years ago Headaches Speech problem CVS risk factors: Age Male Hypertensive Diabetic System Enquiries: No signs of: JACCOL Neurological problems Respiratory difficulties GI / GU / MS problems Drug History: No known allergies Aspirin (od) Amlodepine (od) Herbal tablets GTN Social History: Priest Lives alone in house Hobbies-music, reading Drinks 3-4 units alcohol Non-smoker No use of recreational drugs Family History: Sister lives in Ireland Father died in accident Mother died of cancer No family history of CVD Investigations for Angina Pectoris Linzi Craxford What was done? Basic FBC (normal) Cholesterol (normal) U & E’s (normal) LFT’s (normal) Fasting Glucose (9.1 mmol/L) CRP (normal) CK, Trop T and cardiac enzymes (normal) What was done? Specialised Resting ECG (normal) Exercise tolerance test (ST depression) Chest X-ray (normal) Catheterisation and Angiogram (? Results) What else can be done? Basic Thyroid tests for low TSH and high T3 & T4 Specialised Cardiac scintigraphy Echocardiography MANAGEMENT Initially: Reassurance treat underlying problems other cp-existing problems correctly managed risk factors evaluated and eliminated where possible Prognostic therapies: Aspirin - 75mg daily - decreases risk of coronary events in patients with coronary artery disease. Lipid-lowering agents - used if total cholesterol is greater than 4.8mmol/L Symptomatic treatment: Glyceryl trinitrate (GTN) - given sublingually for acute attacks - taken before exertion If angina is frequent or occurs with only modest exertion prophylactic therapy should be given Prophylactic treatments Beta-adrenergic blocking drugs - reduce heart rate and force of ventricular contraction Calcium antagonists - relax coronary arteries and reduce the force of left ventricular contraction Nitrates - reduce venous and intra cardiac pressures, dilate coronary arteries and reduce impedance to emptying left ventricle Nicordial - nitrate-like activity with potassium channel blockade - useful when there are contraindications to beforementioned agents Coronary Angioplasty Localized atheromatous lesions are dilated at cardiac catheterization using small inflatable balloons gives more complete relief than medical therapy but is associated with a higher rate of myocardial infarction OR bypass surgery as a result of the procedure Surgical management Coronary artery bypass grafting (CABG) - relief is achieved in 90% cases - suitable if medical treatement does not eliminate symptoms or if patient not suitable for angioplasty Causes & Risk Factors Dornu Lebari Pathophysiology of Ischemia Mismatch of myocardial oxygen supply and demand. Atherosclerotic plaques narowing vessel lumen. Recent evidence supports idea of fixed vessel narrowing and abnormal vascular tone . Dornu Lebari Causes of Ischemia Inappropriate vasoconstriction Platelet aggregation Producing reduced oxygen supply to the myocardium. Atherosclerotic plaques. Dornu Lebari Pathophysiology in Anginal syndromes Patent lumen, no platelet aggregation, normal endothelium. Lumen is narrowed by plaque, inappropriate vasoconstriction. Plaque rupture, platelet aggregation, thrombus, unopposed vasoconstriction. No overt plaques, intense vasospasm. Images courtesy of “Pathophysiology of Heart Disease” edited by Leonard S. Lilly. Dornu Lebari Risk factors Alcohol drinking Cigarette smoking Hypercholesterolemia Hypertension Diabetes Family history of Coronary Artery Disease, esp. if premature. Dornu Lebari Classes of Angina Jasdeep Singh Khangura (3rd Year MBBS) Classes of Angina Classical/exertional angina pectoris Decubitus angina Variant (Prinzmetal’s) angina Cardiac syndrome X Unstable angina Classical/ Exertional Angina Pectoris Provoked by physical exertion/ heavy meals/ cold weather Aggravated by anger/ excitement Pain fades quickly (minutes) upon resting Can disappear with continued exertion Predictable certain levels of exertion/ threshold for pain development variable Severity graded by Canadian Cardiovascular Society (CCS) Severity of Pain in Angina (kindly excerpted without permission from Kumar and Clark, 4ed. Table 11.3, page 631) Decubitus Angina Occurs lying down Associated with impaired left ventricular function/coronary artery disease Includes nocturnal angina: Wake patient from sleep Provoked by vivid dreams Critical coronary artery disease resulting in vasospasm Variant (Prinzmetal’s) Angina Angina that occurs w/o provocation e.g. during rest Coronary artery spasm More frequent in women ST elevation during pain Provocation tests hyperventilation testing cold pressor testing ergometrine challenge Arrhythmias (ventricular tachycardia, heart block) during ischaemic episodes Cardiac Syndrome X Includes patients who fulfil following criteria: Patients with history of angina positive exercise test angiographically normal coronary arteries Heterozygous group (functional abnormalities of coronary microcirculation) Prevalence: women>men Good prognosis Highly symptomatic difficult to treat Unstable Angina Includes: Angina of recent onset (<1month) Worsening angina Angina at rest Lead to MI ( in 10% cases) Medical emergency Death in 1 year (5-15% of people) Admission of patient: Bed rest Aspirin ( incidence of death/ MI) Heparin Medical anti-anginal therapy Risk stratifying patients with unstable angina – (low/ intermediate/ high risk) Risk Stratification in Patients with Unstable Angina (kindly excerpted without permission from Kumar and Clark, 4ed. Table 11.3, page 691) Management of Low Risk Unstable Angina Patient discharged Assessed as elective outpatients Intermediate Risk Unstable Angina Controversy/ grey area Early intervention not influence long term outcome Therapies aimed at influencing procoagulant/ thrombogenic state – persist several months following presentation Management of High Risk Unstable Angina Prompt angiography Re-vascularisation