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Chest Pain / Angina Pectoris: Difference between revisions
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But not all hospitals are qualified to perform PCI and therefore fibrinolysis is still used. There are however some circumstances in which transfer to a PCI qualified hospital is essential: | But not all hospitals are qualified to perform PCI and therefore fibrinolysis is still used. There are however some circumstances in which transfer to a PCI qualified hospital is essential: | ||
* Patients with contraindications for fibrinolysis as active bleedings, recent dental surgery, past history of intracranial bleeding.<cite>Grzybowski</cite> | |||
* Patients with cardiogenic shock, severe heart failure and/or pulmonary oedema complicating the myocardial infarction.<cite>Thune</cite>, <cite>Kent</cite> | |||
Or when PCI has a better outcome: | Or when PCI has a better outcome: | ||
* Patients who present three hours to four hours after the onset of the symptoms.<cite>VandeWerf</cite> | |||
* Patients with a non diagnostic ECG or a atypical history a coronary angiography with the ability to perform a PCI is preferred.<cite>VandeWerf</cite> | |||
==Fibrinolysis== | |||
Fibrinolytics like streptokinase stimulate the conversion of plasminogen to plasmin. Plasmin demolishes fibrin which is an important constituent of the thrombus. Fibrinolytics are most effective the first hours after the onset of symptoms, after twelve hours the outcome will not improve.<cite>Bassand</cite> | |||
Because re occlusion after fibrinolysis is possible patients should be transferred to a PCI qualified hospital once fibrinolysis is done.<cite>Silber</cite> | |||
==Percutaneous Coronary Intervention (PCI)== | |||
'''Table 3 Considerations for selecting primary percutaneous coronary intervention (PCI) for reperfusion therapy in patients with ST elevation myocardial infarction (STEMI)''' | |||
The procedure of PCI starts off as a coronary angiography (see CAG). When the stenosis is visualized a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent that the effect of the balloon is only temporarily a stent is positioned at the site of the stenosis. To reduce the risk of coronary artery stent thrombosis antiplatelet therapy should be given. | |||
==CORONARY ARTERY BYPASS GRAFT== | |||
There are circumstances in which CABG should be performed. | |||
'''Table 2''' | |||
CABG does not eliminate the stenosis like PCI does. Using the internal thoracic arteries or the saphenous veins from the legs a bypass is made around the stenosis. The bypass originates from the aorta and terminates directly after the stenosis. Thereby restoring the blood supply to the ramifications. A bypass can be single or multiple, multiple meaning that there are several coronary arteries bypassed using the same bypass. | |||
Major surgery is not preferable in patients with STEMI, but CABG is inevitable when fibrinolysis and/or PCI failed or when the patient develops cardiogenic shock, life threatening ventricular arrhymthmias or three vessel disease.<cite>Antman2</cite> | |||
MEDICATION TO START AFTER MI<cite>Antman3</cite> | |||
β blockers lower heart rate and blood pressure, this decreases the oxygen demand of the heart. | |||
Nitrates dilatate the coronary arteries so the heart receives more oxygenated blood. Anticoagulants reduce the risk of development of a thrombus in the coronary arteries. | |||
Statins to lower cholesterol. | |||
Apart from starting medication the patient needs to minimize any present risk factors like smoking, overweight and drinking alcohol. | |||
=Non ST elevated Myocardial Infarct= | |||
Initial treatment in NSTEMI is to reduce ischemia, stabilize the hemodynamic status, make serial ECG and to repeat measurements of the cardiac markers. Depending on the early risk stratification a choice has to be made between early invasive therapy or conservative therapy with medicines.<cite>Antman</cite> | |||
Early risk stratification is helpful to identify patients at high risk who need a more aggressive therapeutic approach to prevent further ischemic events.<cite>Antman4</cite> | |||
* Age ≥65 years | |||
* Presence of at least three risk factors for coronary heart disease (hypertension, diabetes, dyslipidemia, smoking, or positive family history of early MI) | |||
* Prior coronary stenosis of ≥50 percent | |||
* Presence of ST segment deviation on admission ECG | |||
* At least two anginal episodes in prior 24 hours | |||
* Elevated serum cardiac biomarkers | |||
* Use of aspirin in the prior seven days | |||
Patients with a score of 0 to 1 are at low risk, score 2 to 3 are at intermediate risk, score 4 to 6 are at high risk. | |||
==Conservative Therapy== | |||
The main objective of in hospital conservative therapy is to relieve ischemic pain by intensifying medical therapy with aspirin and clopidogrel orally and nitro-glycerine, heparin and a beta blocker intravenously. If the patients becomes asymptomatic on these medication and is still asymptomatic when the medication is stopped, rest and stress imaging testing will be performed. The advantage of conservative therapy is reduction of the number of unnecessary revascularizations. The disadvantage is a prolonged stay in the hospital. | |||
Up to date: Trials of conservative versus early invasive therapy in unstable angina and non-ST elevation myocardial infarction, geen specifiekere bronvermelding. | |||
==Rest and Stress Imaging Tests== | |||
Rest and stress testing is indicated in patients with:<cite>Klocke</cite> | |||
# Angina pectoris with ECG abnormalities during exercise ECG testing | |||
# Asymptomatic NSTEMI after in hospital conservative therapy | |||
Exercise echocardiography means that an echocardiography is made directly after exercise. The poorly perfused parts of the heart will show less activity.<cite>Amanullah</cite> | |||
Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest.<cite>Brown</cite> | |||
MRI can be done with vasodilatory dobutamine or stimulating adenosine to assess how the heart behaves during exercise.<cite>Kwong</cite> | |||
==Invasive Therapy== | |||
High risk patients, patients with persistent symptoms despite medication or a positive stress test need invasive therapy. Depending on what is seen during coronary angiography PCI or a CABG is indicated. (see PCI/CABG) | |||
Fibrinolytic therapy is not used in NSTEMI.<cite>Ref2</cite> | |||
=Chronic Coronary Disease= | |||
Even though chronic coronary disease mortality rates have declined since 1970 it is still the leading cause of death in many western countries and in an increasing number of non western countries.<cite>Lloyd-Jones</cite> | |||
The cause of the reduction in mortality rates is mainly due to rapid recognition at special cardiac care units and the possibility of early intervention.<cite>Capewell</cite>, <cite>Heidenreich</cite> | |||
But because survivors of a myocardial infarction still face a substantial risk of further cardiovascular events recognizing and reducing of risk factors is very important. | |||
The following risk factors for chronic coronary disease are modifiable and should be tackled.<cite>Yusuf</cite> | |||
'''Cigarette smoking''' damages the endothelium of the blood vessels making it easy for the cholesterol to adhere. Smoking is therefore a leading preventable cause of coronary disease. All patients who smoke should be counselled to give up smoking. Nicotine replacement therapy and behavioural therapy can help. | |||
'''Hypertension''' is like smoking disadvantageous for the endothelium of the blood vessels and so hypertension contributes to the progression of atherosclerosis. Hypertension is defined as a systolic pressure >140 mmHg and/or diastolic pressure >90 mmHg. Patients with hypertension should be first treated with non pharmacologic therapies, including salt restriction, weight reduction in overweight/obese patients, and avoidance of excess alcohol intake. Antihypertensive drugs are indicated in patients with persistent hypertension despite non pharmacologic therapy. Most patients will require multiple antihypertensive drug therapies. | |||
'''Cholesterol''' is the felon in the atherosclerosis tale and therefore cholesterol levels in the blood should be optimal, meaning low LDL levels and high HDL levels. This can be achieved by using statins. | |||
'''Exercise''' lowers morbidity and mortality from coronary disease. | |||
'''Obesity''' increases several risk factors for coronary heart disease, including hypertension, high cholesterol and insulin resistance as well as diabetes. Data show a linear relationship of higher body weight with morbidity and mortality from coronary disease. All patients who are willing, ready and able to lose weight should receive information about behaviour modification, diet, and increased physical activity. | |||
'''A healthy diet''' results in a significantly lower risk of coronary disease. A healthy diet consists of high intake of fruit and vegetables, high fiber intake, a low glycemic index and load, unsaturated fat rather than saturated fat, a limited intake of red or processed meat and intake of omega 3 fatty acids. | |||
Several studies have shown that people who have a high intake of fruit and vegetables have a reduce risk coronary disease. It is possible that this is due to specific compounds in vegetables and fruits, or because people who eat more vegetables and fruits tend to eat less meat and saturated fat. | |||
'''In diabetes mellitus''' tight glycemic control is important to protect against many vascular complications, including coronary disease. | |||
A small amount of '''alcohol''' results in a lower risk of morbidity and mortality from coronary disease. | |||
==Screening== | |||
Because extensive coronary disease can exist with minimal or no symptoms screening for coronary disease has been suggested. Although screening results in indentifying patients at increased risk there is lack of evidence that screening actually improves outcome.<cite>Gibbons</cite> | |||
==References== | ==References== | ||
| Line 176: | Line 238: | ||
#Abrams pmid=3925741 | #Abrams pmid=3925741 | ||
#Henrikson pmid=14678917 | #Henrikson pmid=14678917 | ||
#Antman | #Antman pmid=15289388 | ||
#Fox pmid=17162834 | #Fox pmid=17162834 | ||
#Amanullah pmid=1352191 | #Amanullah pmid=1352191 | ||
| Line 191: | Line 253: | ||
#Puleo pmid=7702648 | #Puleo pmid=7702648 | ||
#Bassand pmid=16311237 | #Bassand pmid=16311237 | ||
#Grzybowski pmid=14532318 | |||
#Thune pmid=16186438 | |||
#Kent pmid=12472924 | |||
#VandeWerf pmid=12559937 | |||
#Silber pmid=f15769784 | |||
#Antman2 pmid=18191746 | |||
#Antman3 pmid=15339869 | |||
#Antman4 pmid=10938172 | |||
#Klocke pmid=12975245 | |||
#Lloyd-Jones pmid=20177011 | |||
#Gibbons pmid=12392846 | |||
#Capewell pmid=11004141 | |||
#Heidenreich pmid=11182101 | |||
#Yusuf pmid=15364185 | |||
#Ref1 pmid=8375424 | #Ref1 pmid=8375424 | ||
#Ref2 pmid=8149520 | |||
</biblio> | </biblio> | ||