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Unstable angina

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by

Ryan Tee Heng Seong

on 10 October 2014

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Transcript of Unstable angina

UA/NSTEMI
Unstable angina
7 types of pain :
Characteristic : crescendo pain
Onset : new onset
Duration : > 30 minutes
Radiation : to new site
Exacerbation : resting pain
Not alleviated by nitroglycerin
Angina post PCI/CABG
Pathophysiology
Diagnosis
Clinical symptoms

ECG : ST depression, deep symmetrical T wave inversion

Cardiac markers : normal for UA, elevated for NSTEMI
Medications
Oral antiplatelet agents
Aspirin
ADP receptor antagonists : clopidogrel, ticlopidine, prasugrel, ticagrelor
IV antiplatelet agents ( Gp IIb/IIIa inhibitors ) : abciximab, tirofiban, eptifibatide

Anticoagulant therapy
Heparin : UFH, LMWH
Anti-Xa inhibitor : Fondaparinux
Anti IIa inhibitor : bivalirudin

Anti-ischemic drug therapy :
sublingual or IV nitroglycerin
B-blockers
Calcium channel blockers (alternative to BBs)

Drugs improving prognosis
ACEi/ARB
Statins
Management
High risk : should be monitored in CCU

Intermediate/High risk :should be given ASA, clopidogrel, UFH (prasugrel maybe given after coronary angiography in high risk patients undergoing PCI)

Low risk : ASA and managed as outpatient with non invasive tests eg stress test
Canadian cardiovascular society classification
I : no limitation of ordinary activity

II : slight limitation of ordinary activity

III : marked limitation of ordinary activity

IV : limitation even in resting state
Concept from Dr Smith
NSTEMI is "MI without occlusion"
Subendocardial ischemia
Hence no ST elevation because there is no transmural infarction

Subendocardium is prone to ischemia
It is susceptible to high LV pressure
Epicardial vessels need to penetrate through the thick myocardium to reach endocardium

RIsk Stratification
What's the likelihood of ACS ?
What's the likelihood of adv.clinical events ?

Risk scores for prognosis of UA/NSTEMI
TIMI Risk Score : less accurate in predicting events, but is simple and widely used
GRACE risk scores
Triage
Assess patient based on :
Clinical status (mental status, perfusion)
Vital signs
Severity of clinical symptoms
History ( prior interventions )
Risk factors ( DM,hypertension, dyslipidemia etc )
Scoring system

Low risk : can be referred as outpatient for cardiac assessment
Intermediate/high risk : benefit from early angiography & revascularisation

ASA and clopidogrel
Aspirin
Loading dose : 300 mg of chewable aspirin
Maintenance : 75-150 mg of enteric coated aspirin
Enteric coated ASA is not used for loading dose due to slow onset

Clopidogrel
Loading dose : 300 mg
Maintenance dose : 75 mg/day
Novel antiplatelet agents
Prasugrel
To date, outcome date only for ACS patients undergoing PCI (more potent than clopidogrel but also causes more bleeding)
Recommended for patients
after
angiography (not
before
due to concern of CABG-related bleeding)
Not recommended in patients > 75 yo, < 60 kg and TIA/past Hx of stroke due to risk of major bleeding

Ticagrelor
Reversible
P2Y12 inhibition, short acting
More effective than clopidogrel without increased risk of CABG-related bleeding
One caveat is that there is also
higher rate of intracranial bleeding
shown in PLATO
Has also shown benefit in patients
before
angiography ("upstream" use)
2 side effects : dyspnoea and ventricular pauses (asymptomatic and does not need pacemaker, normally transient)

Gp IIb/IIIa antagonists
Gp IIb/IIIA allows fibrinogen to bind to platelets, therefore stabilizing the clot formation

These agents maybe used in high risk patients awaiting transfer for an early invasive strategy

However, its routine use as upstream therapy is NO LONGER practiced
BEWARE interaction with omeprazole; it inhibits CYP2C19 which prevents the activation of clopidogrel (a prodrug)
UFH and LMWH
Activates AT III
AT III binds to both factor II and factor X

UFH : monitor aPTT
LMWH : anti-Xa assay
Major side effects
Bleeding
HIT (antibodies formed against PF4, causing activation and exhaustion of platelets)
Fondaparinux
Best used in stable UA/STEMI
Associated with increased in catheter-related thrombus
Therefore, not preferred as sole agent in PCI
If UA/NSTEMI patients require PCI, UFH is better
Other agents
Argatroban and bivalirudin
Can be used as substitute for UFH in HIT with no increased of bleeding
Not yet available in Malaysia
IV nitroglycerin is given if no symptoms relief after 3 doses of sublingual GTN
c/i in right ventricular failure and concomitant ingestion of PDE5- inhibitors
ABCDEFGH of Beta-blockers contraindications
Asthma, AV block
Bradycardia, BP low
COPD
Diabetes, dyslipidemia
Extremities vascular disease, erectile dysfunction
Foetus
Geriatrics
Hyperkalemia, hypothyroidism

Cardioselective Beta blockers are better (atenolol, metoprolol, bisoprolol)
CCBs are only used when BBs are contraindicated. Non-dihydropyridine group is preferred (diltiazem, verapamil)
Statins may reduce CV events due to its pleotropic events

ACEi/ARB benefits those with LV dysfunction as it blunts the neurohormonal activation of RAAS
Revascularization
Urgent : HF, fatal arrhythmias, shock

Early (<72 hours) : high risk patients

Routine invasive evaluation is NOT recommended in low risk patients; but they should have non-invasive tests for inducible ischemia

Selective invasive therapy can be done in those who cannot be stabilized medically / ischemia provoked in the subacute phase (eg via treadmill test)
In Elders
Avoid prasugrel is > 75 yo

Elders have more bleeding complications with use of Gp IIa/IIIb inhibitors

Bleeding risk is also higher with UFH/LMWH

Early invasive therapy confers greater long term benefit, although bleeding risk is also increased
In CKD
A more severe CKD = greater mortality
ACEi/ARB may cause renal function worsening

Increasd bleeding risk due to uremia

Early invasive therapy may have better outcomes but there is increased risk of bleeding and contrast induced nephropathy (contrast is used in angiography)

Drug doses should be adjusted
Discharge Medications
Education (NEWS)
ASA at 75-150 mg/day, clopidogrel as alternative
(for those who have undergone PCI with bare metal stents, dual antiplatelets for 1 month; PCI with DES dual antiplatelets for 1 year)
Beta blockers
Statin (LDL-C < 1.8 mmol/L)
ACEi/ARB especially for LV dysfunction
Aldosterone antagonist : for NYHA stage II and above, selected patients with intact renal fxn
Anti-anginal therapy
Low risk outpatient assessment
Echocardiogram
Treadmill stress test
Stress echocardiography
Nuclear perfusion test
Full transcript