1. Management of Angina
and
Acute Myocardial Infarction

2. CLINICAL PRESENTATIONS

3. I. Stable angina pectoris
Ischaemia due to fixed athromatous
stenosis

4. II. Unstable angina
Dynamic obstruction due to plaque
rupture and superimposed thrombosis

5. III. Acute Myocardial Infarction
Myocardial necrosis due to acute
occlusion of coronary artery

6. Acute Coronary Syndrome
Unstable Angina & AMI

7. Factors infulencing myocardial oxygen
supply and demand
OXYGEN DEMAND
Cardiac work- Heart rate, blood pressure
Myocardial contractility,
LV hypertrophy

8. OXYGEN SUPPLY
Coronary blood flow
Duration of diastole
Coronary perfusion pressure
Coronary vasomotor tone
Oxygenation- haemoglobin
oxygen saturation

9. Activities precipitating angina
Physical exertion
Cold exposure
heavy meals
Intense emotion
Lying flat
Vivid dreams

10. Risk stratification in stable angina
HIGH RISK
Post infarction angina
Poor effort tolerance
Ischaemia at low work load
Lt main or three vessel disease
Poor LV function

11. Low risk
Predictable exertional angina
Good effort tolerance
Ischaemia only at high workload
Single or minor two vessel disease
Good LV function

12. Management of Angina
Careful assessment of the likely extent and
severity of arterial disease
Identification and control of significant risk
factors
Use of measure to control symptoms
Identification of high risk patients and
application of treatment to improve life
expectancy

13. Advice to patient with stable angina
.Do not smoke
.Ideal body weight
regular exercise
.Avoid severe , unaccustomed exercise,
vigorous exercise after heavy meal or in very
cold weather
.Sublingual nitrate before exertion that may
induce angina

14. II. MEDICAL TREATMENT
A. Symptomatic ( prevent or relieve angina
Nitrates- Sublingual / buccal GTN
Transdermal GTN
Oral long acting ntrates
(isosorbide mono/dinitrates)
-Beta blockers- Atenolol 50-100 mg/d
Metoprolol 25-50 mg/d

15. -Ca channel blocker
( when beta blocker is contra-indicated
or in case of coronary spasm)
Nifedipine 5- 20 mg 8 hourly
Nicardipine 20-40 mg 8 hourly
Amlodipine 2.5-10 mg od
Diltiazem 60-120 mg 8 hourly
Verapamil 40-80 mg 8 hourly

16. Potassium channel activator
Nicorandil sodium 10-30 mg 12 hourly

17. B. Prognostic treatment
( To improve long term prognosis and
prevent coronary event )
-Asprin – 75-150 mg/d
-Other antiplatelet – Clopidogrel( if
patient can not tolerate asprin) 75 mg daily
-Lipid lowering agents- Statins,
Fibrates

18. III. SURGICAL ( INVASIVE )
TREATMENT
A. Percutaneous Coronary Intervention
-Balloon angioplasty
-Implantation of coronary stent

19. B. Coronary Artery Bypass Graft
( CABG )
Antiplatelet ( Asprin and
Clopidogrel ) and aggressive lipid
lowering therapy shown to slow
progression of disease in native
coronary vessel and bypass graft

20. Comparism of PCI and CABG
PCI CABG
Death 0.5% 1.5%
MI 2% 10%
Hospital stay 12-36 hour 5-8days
Return to work 2-5 days 6-12weeks
Recurrent angina 30% at 6 month 10% at 1 year
Recurrent
revascularisation 20% at 2 yr 2% at 2 yr
Nerological
complication Rare common
Other complications Emergency CABG Diffuse myocardial
Vascular damage damage
Infection
Wound pain

21. Management of
Acute Myocardial Infarction

22. DIAGNOSIS OF AMI
At least two of the followings
- History of ischaemic type of chest
pain
- Evolving ECG changes
- Rise and fall of cardiac enzymes

23. ST Elevation Q wave

24. CARDIAC ENZYMES
Enzymes Peak Persist
Troponin I 2-4 hours 7 days
CKMB within 24 hours 48 hours
SGOT ( AST ) 48 hours 72 hours
LDH 72 hours 10 days

25. Treatment of
Acute Myocardial Infarction

26. Acute condition
Keep in coronary care unit ( CCU )
provide facilities for defibrillation
High flow oxygen
IV access and ECG monitor for
arrhythmias

27. Pain relief- IV morphine 10mg or
diamorphine 5 mg
with metoclopramide or cyclizine
Asprin -300 mg chewed

28. REPERFUSION
IV thrombolysis with Streptokinase 1.5
million units over 1 hour (within 12 hour
after onset of chest pain)
Other thrombolytic agents- r TPA

29. Urgent PTCA
As primary treatment
Failed thrombolysis
Contraindication to thrombolysis
Re infarction

30. Other treatments
-IV atenolol – improve survival
prevent myocardial rupture
IV nitrate infusion- for persistent pain
Anticoagulants( SC heparin) in addition to
oral asprin may prevent reinfarction after
thrombolysis and prevent DVT and
pulmonary embolism

31. SUBSEQUENT MANAGEMENT
( SECONDARY PREVENTION )
Oral beta blocker ( atenolol ) if LV function
is good
ACEI if LV function is poor
Asprin 75-100 mg/d ay

32. Lipid lowering therapy
Modification of risk factor –
Smoking, exercise, diet
PTAC or CABG

33. ACUTE COMPLICATIONS OF AMI
Cardiac arrest
Cardiac arrhythmias (especially ventricular arrhythmia )
Cardiac conduction disturbance ( heart block )
Cardiac failure- extensive myocardial infarction
Cardiogenic shock
Pericarditis

34. LATE COMPLICATIONS OF AMI
Recurrent angina or infarction
Thromboembolism
Mitral regurgitation – ruptured cordae tendinae/
papillary muscle dysfunction
Ventricular free wall rupture- haemopericardium
Ventricular aneurysm
Acute ventricular septal defect

35. Post-myocardial infarction syndrome
(Dressler'ssyndrome )
Immunological reaction-
fever,arthralgia,pericarditis, pericardial effusion
Recurrent arrhythmias
Shoulder hand syndrome
Psychological- depression

36. POOR PROGNOSTIC FACTORS
Old age
Large infarct
Poor LV function
Residual myocardial ischaemia
Ventricular arrhythmias