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· Symptom complex characterised by attacks of chest pain, causing ischaemia but not infarction
o Stable angina (typical): pain on exertion, relieved by rest or vasodilators. Subendocardial ischaemia with ST-segment depression
o Variant or Prinzmetal‟s angina: classically occurs at rest. Caused by reversible spasm in normal to severely atherosclerotic coronary arteries. Can see ST-segment elevation or depression
o Unstable angina: variable, prolonged pain, pain at rest or worsening of pain in stable angina. ST- segment depression – but may be elevated. Most common complication: arrhythmias (especially VF). Within 3 months 4% will have sudden death and 15% a myocardial infarct
o Sudden cardiac death. Usually within an hour of a cardiac event or without symptoms. Usually high-grade stenosis. Usually associated with arrhythmias, especially ventricular ectopic beats and subsequent VF
· Treatment options for stable angina:
o Nitrates: short & long acting
o b-blockers (¯myocardial O2 consumption)
o Ca antagonists
· Unstable angina:
o = Acute Coronary Syndrome (ACS) = acute heart problems without ST elevation
§ ECG. Serial or continuous if high risk
§ Bloods: Troponin (repeat after 6 hours), FBC, Cr, electrolytes, CK, blood glucose. Want to test lipids/cholestrol – but false positives following an acute coronary event. Do later.
§ CXR: cargiomegaly? Pulmonary oedema? Dissection?
o Medical therapy:
§ Aspirin: reduces progression to MI. Neither Warfarin nor Heparin confers little further benefit. Use heparin if high risk.
§ b-blockers: reduce progression to MI
§ iv nitroglycerine for symptomatic relief
§ Maybe calcium channel blockers that reduce the heart rate
o Low risk:
§ Normal ECG and no detectable troponin despite angina frequency or severity
§ Management: discharge for outpatient assessment
o High risk:
§ If even a minor degree of ST depression or a significant elevation of troponin ® minor myocardial damage so now is the time to act
§ Overlap between High Risk ACS and non-STEMI (non-ST elevation MI)
§ Management: Admit for coronary angiography and, if positive, early percutaneous coronary intervention (ie more aggressive treatment than previously)
· Long term management:
o ¯Obesity, diabetes, smoking, exercise
o Referral to a cardiac rehabilitation programme
o Statins if serum cholesterol raised
o ACE inhibitors if hypertension or diabetes
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