Acute Cardiac Conditions

 

Two types of angina

Angina pectoris

Angina of effort

 

 

 

Acute coronary syndrome

Caused by vascular occlusive pathology

A continuum of increasingly serious pathology

Based on severity and duration of myocardial blood flow and nature of thombus

May progress to more serious forms

 

 

 

Low risk unstable angina

Clinical features

No CK elevation

No troponin increase

 

 

 

High risk unstable angina

Clinical features

No CK elevation

Increased troponins

Minor myocardial damage

 

 

 

Non-STEMI

Clinical features

Increased CK and troponins

 

 

 

STEMI

Clinical features

Increased CK and troponins

ST elevation

 

 

 

Pathology

Unstable angina and NSTEMI, white thrombus, platelets only

STEMI, 80% show red thrombus, fibrin and erythrocyte based thrombus

 

 

 

Management in unstable angina

Bed rest

Aspirin reduces risk of death and MI

Aspirin and clopidogrel reduces risk more

Low molecular weight heparin (e.g. enoxaparin or fondaparinux) with aspirin is better than aspirin alone

Intravenous glycoprotein inhibitors are also antiplatelet and reduce death and MI

Beta blockers, nitrates and calcium channel blockers are anti-ischaemic

Intravenous nitrates if pain persists

Gradual mobilisation

Thrombolysis is not used in unstable angina or non-NSTEMI

 

 

 

 

Management in STEMI

 

Analgesia

Acute reperfusion therapy, thrombolysis, streptokinase, TPA, tenecteplase (a recombinant fibrin specific plasminogen activator)

Primary percutaneous coronary intervention, 50% greater reduction in mortality compared to thrombolysis

Antiplatelet therapy

Anticoagulants in addition to aspirin

Beta blockers

ACE inhibitors, eg. Ramipril

Nitrates

Prevent complications

 

 

 

 

Complications of myocardial infarction

 

Dysrhythmias, e.g.

Ventricular fibrillation

Ventricular tachycardia

Atrial fibrillation

Sinus Bradycardia

Atrioventricular block

Left ventricular failure

Cardiogenic shock

Pericarditis

Mural thrombosis

Ventricular aneurysm

Ventricular rupture

Infarct of a papillary muscle

Ischaemia from residual stenosis

Psychological / spiritual/ social

 

 

 

 

 

 

Secondary prevention after myocardial infarction

 

4-6 weeks for a fibrous tissue repair of infarcted muscle, therefore restrict physical activity for this time, gradual increase

Exercise programme

In smokers 5 year mortality is double in patients who continue as opposed to those that quit

Hypercholesterolaemia

Diet

Statins, risk reduced by 20% per mmol / l reduction in LDL

Weight

ACE inhibitors even if no LVF

Aspirin, reduced risk by 22%, even more with clopidogrel

Manage hypertension

Beta-blockers reduce long mortality by 25%

Treat hypothyroidism

Manage diabetes mellitus

Psychological management, denial, anxiety, depression

Sex with familiar partner is fine

 

 

 

 

 

Risk factors for atherosclerosis

 

 

 

Unknown factors account for 40% of the risk

 

 

 

Known risk factors are multiplicative

 

 

 

Age and Sex

 

 

 

Family history / Race

 

 

 

Smoking

 

 

 

Hypertension

 

 

 

Hypercholesterolaemia and Triglycerides

 

 

 

Diabetes mellitus

 

 

 

Haemostatic factors

 

 

 

Physical activity

 

 

 

Obesity

 

 

 

Alcohol

 

 

 

Personality

 

 

 

Hyperhomocysteinaemia

 

 

 

Lack of vitamin D