Differential Dx of Angina

CASE 2

A 50 – year – old male teacher notices the sudden onset of “chest tightness” when he walks across the parking lot to and from the school. The pain, which is localized over the sternum, goes away when he sits down. He does not experience any pain or discomfort at other times. He has mild hypertension, for which he is on dietary therapy. His cholesterol level is elevated. He does not smoke.

CHIEF COMPLAINT

“ CHEST

TIGHTNESS”

Clinical Scenario: History

Male, 50 yrs. Old Chest tightness when walking for a Short distance

Pain over the SternumPain is relieved by Sitting downHypertensiveHypercholesterolemiaOn Diet Therapy

Differential Diagnosis

PericarditisAcute Myocardial Infarction

Stable Angina Pectoris

What Is Pericarditis? Is a condition in which the membrane, or sac, around

your heart is inflamed. This sac is called the pericardium.

The pericardium holds the heart in place and helps it work properly. The sac is made of two thin layers of tissue that enclose your heart. Between the two layers is a small amount of fluid. This fluid keeps the layers from rubbing against each other and causing friction.

Pericarditis

Figure A shows the pericardium—the sac surrounding the heart. Figure B is an enlarged cross-section of the pericardium that shows its two layers of

tissue and the fluid between the layers.

What Causes Pericarditis?

the cause of about half of all pericarditis cases (both acute and chronic) is unknown.

Viral infections are likely the most common cause of acute pericarditis, but the virus may never be found. Pericarditis often occurs after a respiratory infection. Bacterial, fungal, and other infections also can cause pericarditis.

Less often, pericarditis is caused by:

Autoimmune disorders, such as lupus, scleroderma, and rheumatoid arthritis

Heart attack and heart surgery

Kidney failure, HIV/AIDS, cancer, tuberculosis, and other health problems

Injury from accidents or radiation therapy

Certain medicines, like phenytoin (an antiseizure medicine), warfarin and heparin (blood-thinning medicines), and procainamide (a medicine to treat abnormal heartbeats)

The causes of acute and chronic pericarditis are the same.

Who Is At Risk for Pericarditis?

Pericarditis occurs in people of all ages. However, men between the ages of 20 and 50 are more likely to get it.

People who are treated for acute pericarditis may get it again. This may happen in 15 to 30 percent of people who have the condition. A small number of these people go on to develop chronic pericarditis.

Sharp, stabbing chest pain is a common symptom of acute pericarditis. The pain usually comes on quickly. It often is felt in the middle or the left side of the chest.

The pain tends to ease when you sit up and lean forward. Lying down and deep breathing worsens it. For some people, the pain feels like a dull ache or pressure in their chests.

Fever is another common symptom of acute pericarditis. Other symptoms are weakness, trouble breathing, and coughing.

What Are the Signs and Symptoms of Pericarditis?

Chronic pericarditis often causes tiredness, coughing, and shortness of breath. Chest pain is often absent in this type of pericarditis. Severe cases of chronic pericarditis can lead to swelling in the stomach and legs and low blood pressure (hypotension).

What symptoms are associated with pericarditis?

The most common symptom caused by pericarditis is chest pain. The pain can severe, and is often made worse by changing position or with deep breathing. Patients can also have shortness of breath, or fever.

Pericarditis can produce complications, namely tamponade, chronic pericarditis, and constriction. These complications - which are discussed below – can produce reduced cardiac pumping, lung congestion, and organ failure.

Complications of Pericarditis

Two serious complications of pericarditis are:

cardiac tamponade

chronic constrictive pericarditis.

Cardiac tamponade

occurs when too much fluid collects in the pericardium (the sac around the heart). The extra fluid puts pressure on the heart. This prevents the heart from properly filling with blood. As a result, less blood leaves the heart. This causes a sharp drop in blood pressure. If left untreated, cardiac tamponade can cause death.

Chronic constrictive pericarditis

is a rare disease that develops over time. It leads to scar-like tissue throughout the pericardium. The sac becomes stiff and can’t move properly. In time, the scarred tissue compresses the heart and prevents it from working correctly.

Myocardial Infarction (MI)

What is MI?"Myocardial Infarction" (abbreviated as

"MI") means there is death of some of the muscle cells of the heart as a result of a lack of supply of oxygen and other nutrients.

is the rapid development of myocardial necrosis caused by a critical imbalance between oxygen supply and demand of the myocardium

Cause of MI:

The most frequent cause of myocardial infarction (MI) is rupture of an atherosclerotic plaque within a coronary artery with subsequent arterial spasm and thrombus formation.

Other causes:

Coronary artery vasospasmVentricular hypertrophy (eg, left ventricular

hypertrophy [LVH], idiopathic hypertrophic subaortic stenosis [IHSS], underlying valve disease)

Hypoxia due to carbon monoxide poisoning or acute pulmonary disorders (Infarcts due to pulmonary disease usually occur when demand on the myocardium dramatically increases relative to the available blood supply.)

Coronary artery emboli, secondary to cholesterol, air, or the products of sepsis

Cocaine, amphetamines, and ephedrine

Other causes:

ArteritisCoronary anomalies, including

aneurysms of the coronary arteriesIncreased afterload or inotropic

effects, which increase the demand on the myocardium

Aortic dissection, with retrograde involvement of the coronary arteries

Risk factors:

Age-older than 45 years oldMale genderSmokingHypercholesterolemia and

hypertriglyceridemia, including inherited lipoprotein disorders

Diabetes mellitusPoorly controlled hypertensionFamily historySedentary lifestyle

Signs & Symptoms:

Chest painDyspneaNausea& abdominal painAnxietyLightheadedness with or without syncopeCoughNausea with or without vomitingDiaphoresisWheezing

Complications:

Complication type: Manifestations:

•Ischemic

•Mechanical

•Arrhythmic

•Embolic

•Inflammatory

•Angina, reinfarction, infarct extension•Heart failure, cardiogenic shock, mitral valve dysfunction, aneurysms, cardiac rupture•Atrial or ventricular arrhythmias, sinus or atrioventricular node dysfunction•Central nervous system or peripheral embolization

•Pericarditis

ANGINA PECTORIS

Angina pectoris

most common clinical manifestation of CAD

results from an imbalance between myocardial O2 supply and demand, most commonly resulting from atherosclerotic coronary artery obstruction.

Other major conditions that upset this balance

and result in angina include aortic valve disease, hypertrophic cardiomyopathy, coronary artery spasm.

STABLE ANGINA

• Usually develops gradually with exertion, emotional excitement, or after heavy meals.

• •Rest or treatment with nitroglycerin leads to relief.

• In contrast, pain that is fleeting is rarely ischemic in origin.

• Pain that last for several hours is unlikely to represent angina.

STABLE ANGINA

• Most myocardial perfusion occurs during diastole, when there is minimal pressure opposing coronary artery flow.

• Tachycardia decreases the percentage of time in which the heart is in diastole. It decreases myocardial perfusion.

UNSTABLE ANGINA

• Similar in quality to angina pectoris.

• More prolonged ang severe.

• Occur with the patient at rest, or awakened from sleep.

• Sublingual nitroglycerin may lead to transient or no relief.

• Accompanying Sx: Diaphoresis, dyspnea, nausea and light-headedness.

UNSTABLE ANGINA

• Auscultation: During ischemic episodes there will be presence of third or fourth heart sounds.

• This reflects myocardial systolic or diastolic dysfunction.

• Presence of transient murmur of mitralregurgitation suggests ischemic papillary muscular dysfunction.

PRINZMETAL’S ANGINA

• CAUSES: The spasm often occurs in coronary arteries that have not become hardened due to plaque buildup (atherosclerosis). However, it also can occur in arteries with plaque buildup.

• The coronary artery may appear normal during angiography, but it does not function normally.

PRINZMETAL’S ANGINA

• Coronary artery spasm occurs most commonly in people who smoke or who have high cholesterol or high blood pressure.

• It may be triggered by:Alcohol withdrawal,emotional stress ,exposure to cold,medications, and stimulant drugs such as amphetamines and cocaine.

PRINZMETAL’S ANGINA

• Symptoms: Spasm may be "silent" --without symptoms -- or it may result in chest pain or angina.

• If the spasm lasts long enough, it may even cause a heart attack.

• The main symptom is a type of chest pain called angina, felt under the chest bone and is described as:

PRINZMETAL’S ANGINA• Constricting,crushing,pressure,squeezing,

tightness.

• It is usually severe. The pain may spread to the neck, jaw, shoulder, or arm.

•The pain often occurs at rest and may occur at the same time each day,usually between midnight and 8:00 AM

• Lasts from 5 to 30 minutes

PRINZMETAL’S ANGINA

• The person may lose consciousness.

• Chest pain and shortness of breath are often not present during walking and exercise.

Angina PectorisP( provoking) – eating too much

• exercise• emotion• cold

P ( Palliating/ relieving) – Rest and Nitroglycerin ( sublingual)

Q ( quality) – steady; precordial pressure (“hollow-block”)

- dull, aching, squeezingR ( region) – precordialR ( radiation) - radiate to Left axilla, left under

surface of arms and forearms—little finger then it goes up—

left shoulder and jaw. S (severity) – mild-severe

Etiology of the Signs & Symptoms

Chest Tightness (relieved by rest)

– Ischemia manifests most frequently as chest discomfort.

● Myocardial ischemia occurs when the oxygen supply to the heart is not sufficient to meet metabolic needs. This mismatch can result from a decrease in oxygen supply, a rise in demand, or both

● The most common underlying cause of myocardial ischemia is obstruction of coronary arteries by atherosclerosis

Hypertension:

– Vascular radius and compliance of resistance arteries are important determinants of arterial pressure

– With atherosclerosis, results to narrowing of the blood vessel lumen; damage of the arteries

– Consequently small decreases in lumen size significantly increase resistance causing increased arterial pressure (HPN)

Elevated Cholesterol Level

– Major risk factor in the development of atherosclerosis

– The incidence of CHD is correlated with elevated levels of LDL cholesterol and triacylglycerols and with low levels of HDL cholesterol.

– Cholesterol levels may be elevated as a result of an individual's lifestyle (for example, by lack of exercise and consumption of a diet containing excess saturated fatty acids)

Clinico- Pathologic Correlation

Etiology

Clinical findings

Heart sounds

Normal heart sound Pericardial Friction rub

MORPHOLOGY

Myocardial Ischemia (ANGINA PECTORIS)

Myocardial Ischemia

(also known as angina) is a heart condition caused by a temporary lack of oxygen-rich blood to the heart. There are three types, each of which is signified by pain. The stable type occurs when the heart is working harder than usual and generally goes away with rest; unstable myocardial ischemia is dangerous and requires emergency treatment; variant (also called Prinzmetal's angina) occurs at rest and can be relieved by medicine.

Myocardial Ischemia

There is an imbalance between the supply and demand of the heart for oxygenated blood.

In more than 90% of cases, the cause of myocardial ischemia is reduction in coronary blood flow due to atherosclerotic coronary arterial obstruction. In most cases, there is a long period (decades) of silent, slowly progressive, coronary atherosclerosis before these disorders become manifest.

A fixed obstructive lesion of 75% or greater (i.e., only 25% or less lumen remaining) generally causes symptomatic ischemia induced by exercise.

Atheroma of coronary artery

Stable angina results from increases in myocardial oxygen demand that outstrip the ability of markedly stenosed coronary arteries to increase oxygen delivery but is not usually associated with plaque disruption.

A 90% stenosis can lead to inadequate coronary blood flow even at rest. Slowly developing occlusions may stimulate collateral vessels over time, which protect against distal myocardial ischemia and infarction even with an eventual high-grade stenosis.

Risk factors of Angina Pectoris

Smoking tobacco

• Smoking and long-term exposure to secondhand smoke damage the interior walls of arteries — including arteries to your heart — allowing deposits of cholesterol to collect and block blood flow.

Diabetes

Diabetes is the inability of your body to produce or respond to insulin properly.

Insulin, a hormone secreted by your pancreas, allows your body to use glucose, which is a form of sugar from foods.

Diabetes greatly increases the risk of coronary artery disease, which leads to angina and heart attacks by speeding up atherosclerosis and increasing your cholesterol levels

High blood pressure

Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries.

Over time, high blood pressure damages arteries by accelerating atherosclerosis.

High blood pressure can be an inherited problem.

The risk of high blood pressure increases as you age, but the main causes are eating a diet too high in salt, stress, inadequate exercise and being overweight.

High blood cholesterol or triglyceride levelsCholesterol is a major part of the deposits that can narrow

arteries throughout your body, including those that supply your heart. A high level of the wrong kind of cholesterol in your blood increases your risk of angina and heart attacks.

Low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) is most likely to narrow arteries.

A high LDL level is undesirable and is often a byproduct of a diet high in saturated fats and cholesterol.

A high level of triglycerides, a type of blood fat related to your diet, also is undesirable.

However, a high level of high-density lipoprotein (HDL) cholesterol (the "good" cholesterol) is desirable and lowers your risk of angina and heart attacks.

Personal or family history of heart disease

If you have coronary artery disease or if you've had a heart attack, you're at a greater risk of developing angina.

Older age. Men older than 45 and women older than 55 have a greater risk than younger adults.

Lack of exercise. An inactive lifestyle contributes to high blood cholesterol levels and obesity. Exercise is beneficial in lowering high blood pressure. However, it is important to consult with your doctor before starting an exercise program.

Obesity

Obesity raises the risk of angina and heart disease because it's associated with high blood cholesterol levels, high blood pressure and diabetes.

Also, your heart has to work harder to supply blood to the excess tissue.

Stress

*You may respond to stress in ways that can increase your risk of angina and heart attacks.

• If you're under stress, you may overeat or smoke from nervous tension.

• Too much stress, as well as anger, can also raise your blood pressure.

• Surges of hormones produced during stress can narrow your arteries and worsen angina.

Diagnosis of

Angina

Pectoris

History

The typical patient with angina is a man >50 years or a woman > 60 years who complains of chest discomfort, usually described as heaviness, pressure, squeezing, smothering, or choking and only rarely as frank pain.

History

When the patient is asked to localize the sensation, he/she will typically press on the sternum, sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort ( Levine’s sign)

The angina is usually crescendo – decrescendo in nature and usually lasts 2 – 5 mins and can radiate to the left shoulder and to both arms, especially to the ulnar surface of the forearm and hand.

History

It can also radiate to the back, interscapular region, root of the neck, jaw, teeth, and epigastrium.

Angina rarely localize below the umbilicus or above the mandible.

History

Although episodes of angina are typically caused by exertion or emotion and are relieved by rest, they may also occur at rest and at night while the patient is recumbent.

The patient may be awakened at night distressed by typical chest discomfort and dyspnea.

History

The threshold for the development of angina pectoris may vary by time of day and emotional state.

Many patients report fixed threshold for angina, which occurs predictably at a certain level of activity, such as climbing two flights of stairs at a normal pace.

History

Angina may also be precipitated by unfamiliar tasks, a heavy meal, exposure to cold, or a combination.

It is also important to uncover family history of Ischemic Heart Disease and presence of diabetes mellitus, hyperlipidemia, hypertension, and cigarette smoking.

The history of typical angina pectoris establishes the diagnosis of Ischemic Heart Disease until proven otherwise.

Physical Examination

This is often normal in patients with stable angina, but it may reveal evidence of atherosclerotic disease at other sites, such as an abdominal aortic aneurysm, carotid arterial bruits, and diminished arterial pulse in the lower extremities.

There may also be signs of anemia, thyroid disease, and nicotine stains on the fingertips from cigarette smoking.

Physical Examination

Palpation may reveal cardiac enlargement and abnormal contraction of the cardiac impulse.

Auscultation can uncover arterial bruits, a third or fourth heart sound, and if acute ischemia or previous infarction has impaired papillary muscle function, an atypical systolic murmur due to mitral regurgitation

Physical Diagnosis

Examination during and anginal attack is useful, since ischemia can cause transient left ventricular failure with the appearance of a third or fourth heart sound, a dyskinetic cardiac apex, mitral regurgitation and even pulmonary edema.

Tenderness of the chest wall or reproduction of pain with palpation of the chest discomfort makes it unlikely that it is caused by angina.

Laboratory Examination

The urine should be examined for evidence of diabetes mellitus and renal disease (including microalbuminuria) since these conditions accelerate atheroschlerosis.

Similarly examination of the blood should include measurements of lipids (total cholesterol, LDL, HDL, and triglycerides), glucose, creatinine, hematocrit and thyroid function.

Laboratory Examination

A chest x-ray is important, since it may show the consequences of IHD like cardiac enlargement, ventricular aneurysm, or signs of heart failure. These signs support the diagnosis of IHD and are important in assessing the degree of cardiac damage.

Chest X-ray findings:

Electrocardiogram

A 12 – lead ECG recorded at rest is normal in about half of the patients with typical angina pectoris, but there may be signs of an old myocardial infarction.

Repolarization abnormalities like ST – segments and T- wave changes as well as intraventricular hypertrophy and intraventricular conduction disturbances, are suggestive of IHD, but they are nonspecific, since they can also occur at pericardial, myocardial and valvular heart disease.

Electrocardiogram

Typical ST – segment and T – wave changes that accompany episodes of angina pectoris and disappear thereafter are more specific.

Stress Testing

The most widely used test for both the diagnosis of IHD and estimating the prognosis involves recording the 12 – lead ECG before, during, and after exercise, usually on a treadmill.

The test consists of a standardized incremental increase in external workload while the symptoms, ECG, and arm blood pressure are monitored.

Stress test

Stress Testing

Performance is usually symptom – limited, and the test is discontinued upon evidence of chest discomfort, severe shortness of breath, dizziness, severe fatigue, ST – segment depression, a fall in systolic blood pressure or the development of ventricular tachyarrythmia.

Stress Testing

This test seeks to discover any limitation in exercise performance, to detect typical ECG signs of myocardial ischemia, and to establish their relationship to chest discomfort.

When interpreting ECG stress tests, the probability that coronary artery disease (CAD) exists in the patient should be considered.

Stress Testing

Overall, false – positive or false – negative results occur in one third of cases.

However a positive result on exercise indicates that the likelihood of CAD is 98% in males >50 years with a history of typical angina pectoris and who develop chest discomfort during the test.

Stress Testing

It is increased in patients taking cardioactive drugs such as digitalis and quinidine, or in those with intraventricular conduction disturbances, resting ST – segment and T – wave abnormalities, ventricular hypertrophyor abnormal serum potassium levels.

Since the overall sensitivity of exercise stress electrocardiography is only 75%, a negative result does not exclude CAD, although it makes the likelihood of three – vessel or left main CAD extremely unlikely.

Cardiac Imaging

The imaging is carried out both immediately after cessation of exercise to detect regional ischemia and 4 h later to confirm reversible ischemia and regions of persistent absent uptake that signify infarction

Cardiac Catheterization Laboratory

Coronary Angiogram

Employs Contrast Media via Moving Radiography

Cardiac Imaging

Two dimensional echocardiography can asses both global and regional wall motion abnormalities of the left ventricle due to myocardial infarction or persistent ischemia.

Stress echocardiography may cause the emergence of regions of akinesis or dyskinesis not present at rest.

Cardiac Imaging

Echocardiography or radionuclide angiography should be carried out to asses left ventricular function in patients with chronic stable angina and in patients with a history of a prior myocardial infarction, pathologic Q waves or clinical evidence of heart failure.

2- D Echo

Coronary Arteriography

This diagnostic method outlines the lumina of the coronary arteries and can be used to detect or exclude serious coronary obstruction. However, coronary arteriography provides no information regarding the arterial wall, and severe atherosclerosis that does not encroach on the lumen may go undetected

Coronary Arteriography

Coronary arteriography is indicated in patients with chronic stable angina pectoris

who are symptomatic despite medical therapy and who are being considered for revascularization

patients with troublesome symptoms that present diagnostic difficulties in whom there is need to confirm or rule out the diagnosis of IHD.

Patients with known or possible angina pectoris who have survived cardiac arrest

Coronary Arteriography

Coronary arteriography is indicated in Patients with angina or evidence of

ischemia on noninvasive testing with clinical or laboratory evidence of ventricular dysfunction

Patients judged to be at high risk of sustaining coronary events based on signs of severe ischemia on noninvasive testing, regardless of the presence or severity of symptoms.

Complications of Angina Pectoris

Complications

Cardiac arrhythmias Ventricular tachycardia Heart block Atrial fibrillationCongestive heart failureMyocardial infarctionDressler’s syndromeMitral regurgitationPericarditisPulmonary embolismShockStrokeSudden deathVentricular aneurysm

Cardiac arrhythmia

Abnormal heart rate/ rhythmAny abnormality or disturbance in the

impulse can result in arrhythmia

Congestive Heart Failure

Heart’s function as a pump is inadequate to meet the body’s need

May affect the left ventricle, right ventricle or both

Myocardial Infarction

Occurs when a blood clot completely obstructs an artery supplying blood to the heart

Dressler’s Syndrome-complication that can occur after a heart attack-inflammation of the pericardium that is thought to be an autoimmune disease-chest pain worsens with leaning forward or taking a deep breath

Mitral Regurgitation-backflow of blood from the left ventricle to the left atrium due to mitral insufficiency from incomplete closure of the mitral valve

Pericarditis-inflammation of the sac surrounding the heart-mostly caused by viral infection-chest pain worsens with movement and taking a deep breath

Pulmonary embolism

Pulmonary embolism-obstruction of the pulmonary artery or branch

of it leading to the lung by a blood clot that breaks off

-prevents blood from reaching the lungShock- life threatening condition that prevents

the heart and bloodstream from delivering enough oxygen to keep up with the demand of the body

Stroke- sudden onset focal neurologic deficitSudden deathVentricular aneurysm- bulging in the

ventricle of the heart

Prognosis

Principal prognostic indicators in Patients with IHD

functional state of the left ventricleLocation and severity of coronary artery

narrowingSeverity of myocardial ischemia

Increased risk for adverse coronary events

Angina pectoris of recent onset Unstable angina Angina unresponsive / poorly responsive to therapy

accompanied by symptoms of CHF Most importantly,

Signs during noninvasive testing Strongly positive exercise test showing onset of

myocardial ischemia at low workloads before completion of stage II (Bruce Protocol) exercise test

Decline in systolic pressure >10mmHg during exercise

Development of large /multiple perfusion defects or increased lung uptake during stress radioisotope perfusion imaging

-decrease in left ventricular ejection fraction during exercise on radionuclide ventriculography or during stress echocardiography

Cardiac catheterization-elevation in left ventricular end diastolic pressure and ventricular volume-reduced ejection fraction

Excellent prognosis- patient with chest discomfort but normal left ventricular function

Obstructive lesion of the left anterior descending coronary artery proximal to the origin of 1st septal artery- associated with greater risk than lesion of the R/L circumflex

Stenosis of left main coronary is associated with mortality rate of 15%/ year

Stable angina- marker of underlying CHD

Angina Pectoris Treatment

SELF CARE AT HOME

Stop doing whatever it is that causes the symptoms

Call for helpLie down in comfortable position with

head upAspirinNitroglycerinBring to Hospital Emergency

department

At the Hospital

IV lineAspirin (unless taken one)Oxygen (face mask or canula)

MEDICATIONS

Nitroglycerin sublingual, transdermal relieves angina symptoms by expanding

blood vessels and decreasing the muscle's need for oxygen

taken only when the patient actually has symptoms or expect to have them.

Slow - or long-acting nitroglycerin can be used as a preventative treatment for angina but not until beta blockers are tried first.

Calcium channel blockers are used primarily when beta blockers cannot be

used and/or the patient is still having angina with beta blocker

also lower blood pressure and certain ones slow heart rate.

taken every day

ACE inhibitors also vasodilators with both symptomatic

and prognostic benefit

Statins lower cholesterol and stabilize the fatty plaque on the

inner lining of the coronary artery, even when the blood cholesterol is normal or minimally increased.

Low density lipoprotein (LDL) levels should be less than 70 mg/dL for those at high risk of heart disease.

Beta blockers: lessen the heart's workload slow the heart rate, decrease blood pressure, and lessen

the force of contraction of the heart muscle, this decreases the heart's need for oxygen and thus decreases angina symptoms

Beta blockers are taken every day, regardless of whether the patient is having symptoms, because they are proven to prevent heart attacks and sudden death.

Heparin medications enoxaparin (Lovenox®), dalteparin (Fragmin®), and nadroparin (Fraxiparin®) Frequent blood tests are needed to monitor the concentration of heparin in the blood.

IIb/IIIa inhibitors eptifibatide (Integrelin®), tirofiban (Aggrastat®), and abciximab (ReoPro®).almost completely prevent the formation of blood clots and may help dissolve existing blood clots. Adding these agents to standard treatment regimens for unstable angina may reduce the risk for unstable angina progressing to heart attack.

Warfarin (Coumadin®) anticoagulant that is prescribed for patients who have a history of or are at risk for formation of blood clots (thrombosis)

AspirinDaily aspirin therapy is mandatory to decrease the possibility of sticky platelets in the blood starting a blood clot

Clopedigrol (Plavix®) slightly more potent than aspirin, is considered a long-term alternative to aspirin therapy. Clopedigrol is usually taken in a dose of one 75 mg tablet daily

Heparin medications enoxaparin (Lovenox®), dalteparin (Fragmin®), and nadroparin (Fraxiparin®) Frequent blood tests are needed to monitor the concentration of heparin in the blood.

IIb/IIIa inhibitors eptifibatide (Integrelin®), tirofiban (Aggrastat®), and abciximab (ReoPro®).almost completely prevent the formation of blood clots and may help dissolve existing blood clots. Adding these agents to standard treatment regimens for unstable angina may reduce the risk for unstable angina progressing to heart attack.

Warfarin (Coumadin®) anticoagulant that is prescribed for patients who have

a history of or are at risk for formation of blood clots (thrombosis)

Miscellaneous anti-anginal drugs In 2006, the FDA approved ranolazine (Ranexa). Because of

its side effects (potential to cause abnormal heart rhythm), is indicated only after other conventional drug treatments are found to be ineffective

If inhibitor ivabradine provides pure heart rate reduction leading to major anti-

ischemic and antianginal efficacy. Zinc supplementation

SurgeryPercutaneous Transluminal Coronary Angioplasty

PTCA, angioplasty, balloon dilation or balloon angioplasty coronary arteriography a thin, flexible plastic tube (catheter) with a balloon is inserted

into an artery in the arm or groin with local sedation and advanced to the blockage. Then the balloon is inflated, squeezing open the fatty plaque deposit.  Then the balloon is deflated and the catheter is withdrawn. Often a stent, which is a small metal sleeve, is also placed to hold the artery open.

Coronary Artery Bypass Surgery chest and rib cage are opened up The narrowed part of the artery is bypassed by a piece of vein

removed from the leg, or with a piece of artery behind the sternum (internal mammary artery), or a portion of the radial artery taken from the lower arm or forearm.

Several arteries can be bypassed in one operation.

Angioplasty by Stenting procedure

Transmyocardial Revascularization for people who cannot undergo angioplasty or surgery. simple incision is made in the chest, and a laser is used

to "drill" small holes through the outside wall of the heart into the left ventricle.

About 20-40 holes are made. Bleeding from these holes is minimal and usually stops

after a few minutes of pressure. not clear why this helps relieve angina. One theory is

that it stimulates growth of new blood vessels that improve blood flow to the heart. Other investigators believe it is a placebo effect.

Current research is focusing on trying to find growth factors that could be injected into coronary arteries or directly into the left ventricle to encourage growth of new blood vessels

Laser angioplasty

a catheter with a laser on its tip is used to open the blockage may be accompanied by stent placement

Atherectomy

a catheter has a rotating shaver on its tip to cut away the plaquemay be accompanied by stent placement

Enhanced External Counterpulsation (EECP® therapy)

with chronic stable angina that is unresponsive to medical therapy noninvasive outpatient procedure, it usually is administered during 35 treatment hours, divided into one or two 60-minute treatment sessions per day, 5 days per week. patient lies on a padded table and adjustable cuffs are wrapped firmly around the calves, lower thighs, and upper thighs. These cuffs are connected to inflation and deflation valves that are controlled by an electrocardiogram. When the heart rests, the cuffs are inflated sequentially and rapidly from the lower leg to the upper leg and then are deflated just before the heart beats. This results in an increased blood supply to the heart while reducing its workload.

PreventionStop smoking and using nicotine in any form. Control high blood pressure. Lower blood fatsMaintain a healthy weight. Control diabetes and blood sugarIf a person already has atherosclerosis and angina, they

can learn to take precautions to avoid having symptoms. Avoiding the "triggers"

Do not use caffeine, cocaine, amphetamines, or other stimulants

Drink alcohol moderately (no more than 1-2 drinks daily)Avoid large and heavy meals that leave you feeling

"stuffed" Decrease stress regular exercise routine If the patient has been exercising

strenuously, they may need to cut back to avoid symptoms. aspirin daily

-The end-