Ukindia Angina and Heart Attack
Angina
Defined as exertional chest pain or breathlessness due to coronary ie heart artery blockage . If at rest and accompanied with sweating etc. it is termed unstable angina and may be due to plaque rupture .History taking should ask for smoking , overweight , low thyroid , high blood pressure , diabetes , high cholestrol and family history.
Examination includes pulse , blood pressure , heart sounds and size , lung sounds , abdomen , peripheral pulses , carotids , fundii.
Tests include fasting blood sugar , electrolytes for kidneys , full blood count for anemia , thyroid levels , lipids , chest xray ecg to check for st segment depression , infarct q waves , left ventricular hypertrophy , pulse irregularity .
Aim is to increase exercise , reduce weight , stop smoking , give aspirin to stop platelets aggregating , get cholestrol to below 4.8 ie the cardiac risk factor below 15% by starting on a statin .
Most are referred for an exercise treadmill test -ett- and looking for st segment depression or elevation at rest or during the nine minute test . If there is t wave inversion , the time it takes to come back to normal is checked .
Some go on to angioplasty where a catheter threaded through the leg artery injects dye into the coronary arteries and the size of their lumen is measured . Those with narrowing in single or 2 vessels or where the lesion is proximal can have balloon angioplasty and a stent put in .
More severe cases eg multivessel , left main stem with or without impaired lv function may need a graft connecting the internal mammary artery to the distal part for the front of the heart , which lasts over 20 years or a graft of the saphenous vein for the back of the heart which lasts eight years . Newer techniques like lasers drilling into heart muscle have not been evaluated . The holes tend to block. Drilling into the coronary arteries and keyhole surgery are new.
If the angiogram is positive but the patient is asymptomatic then medical treatment is advised , if sympotmatic afterwards operation . Medical treatment consists of aspirin , clopidogrel (plavix) in those intolerant to aspirin , glceryl trinitrate , betablockers , statins .
Pain afterwards can be treated with spinal stimulation , tens , stellate ganglion block .
Unstable Angina
This is due to ruptures from plaques and gives multi small infarcts in the muscle . Ecg shows widespread ischaemia and troponin levels tend to rise at eight hours of an infarct and stay high for 3 weeks . Apart from above medications aspirin , betablockers , plavix , iv nitrite , low molecular weight heparin , ikorel (nicorandil) are used . Angiogram and ballon angioplasty or graft after ett are considered .
There is some evidence that chlamydia a bacterium sensitive to erythromycin and other drugs is the cause of the cholestrol deposit build up and that these antibiotics can prevent heart attacks.
Heart Attack
Main aim is rapid dissolving of the clot with tpa , so patients should dial 999 and get to the hospital within two hours . Analgesia , betablockers for 2m to 2 years , ace inhibitors to help remodel the heart , statin , rehabilitation , ett and angiogram . Non q infarction means that there may be just stenosis rather than blockage and the full thickness of the heart has not been affected .
A lot of patients die from ventricular fibrillation and an implanted defibrillator can prevent these deaths.