Question

1. What alert would you have for a  patient with Coronary Artery Disease/Angina?

2. What are the important assessments to make?

3. What complications may occur?

4. What interventions will prevent complications?

5. What will you do if the complications occur?

Answer 1

Coronary Artery Disease /Angina

Essentials:

   Angina: The pain provoked by Myocardial ischemia is usually caused by Obstructive Coronary artery disease (CAD), that is sufficiently severe to restrict oxygen delivery to the cardiac myocytes, it is one of the most common initial manifestations of CAD.

Differential Diagnosis:

a) Severe anemia,

b) Left ventricular Hypertrophy secondary to hypertension or Aortic stenosis

   Syndrome-X exclusion from Angina and unobstructed coronary arteries.

Alert and Assessment

- collect the previous clinical Hx which is most useful basis for diagnosis and referral decisions to specialist services,

- commonest indications being as to know whether it is a) new onset Angina,

b) exclusion of Angina in high risk individuals with atypical symptoms,

c) worsening Angina in a patient with previous stable symptoms,

d) new or recurrent angina in a patient with Hx of MI or Coronary Revascularization,

e) assessment of occupational fitness

   As a primary responder in ER or in wards prepare documentation and act according to worsening of disease.

Document the investigation report which are very useful for Primary diagnosis:

Viz: Excercise ECG,

   Myocardial Perfusion Imaging,

   Stress echocardiography,

   Multidetector CT.

Clinical Assessment: A careful Hx of the character,location,radiation,provocation,and duration of chest pain provides most useful diagnostic information,

- Typically angina is experienced as a constricting, centrally located chest discomfort, radiating to the arms, throat, jaw, provoked by exertion, less commonly by stress and usually relived by rest 5 to 10 minutes.

- diagnostic probability is influenced by other risk factors such as

1. Diabetes Mellitus,

2.smoking,

3.Hypertension,

4,Dyslipedemia

Hence, while assessing the patient collect all the information as above said...

Emergency Department triage and Management: In hospital evaluation is required in the remainder, where the symptoms are unclear, ECG is not diagnostic or if significant CO morbidity is present( ex: Bleeding risks)

   An integrated strategy involving the paramedic or ambulance system, emergency physician and cardiologists required

  Should have fast track systems like from ER to catch lab.

  These are facilitated by specifically trained medical and nursing staff with the aim of ensuring clinical assessment and ecg within 15 minutes of arrival and rapid transfer for PCI for thrombolytic therapy within 30 minutes.

Complications of Coronary Artery Disease:

The acute coronary syndrome (ACS) is precipitated by

- change in atheromatous plaque, resulting in increased obstruction to perfusion and ischemia or infraction in the territory supplied by the affected vessel,

- clinical consequences leads to from sailent episode ,Unstable symptoms of ischemia without infraction,

- Progressive infraction,

- Heart failure,

- Sudden death.

Severity of complications:

1. Unstable Angina : typical ischemic symptoms without ST-Elevation on ECG and without elevated biomarkers of necrosis,

2.NSTEMI,

3.STEMI,

Interventions for Prevention:

Interventions mainly achieves an acute reperfusion strategy,

- PCI ( Primary Percutaneous Coronary Intervention),

- Thrombolysis,

If Complication occur: The management of sudden cardiac arrest requires special attention: at least as many lives saved by prompt resuscitation and defibrillation as by reperfusion.

Management:  

  1. Anti ischemic therapy

   - Nitrates, Beta-Blockers,Calcium entryblockers. Potassium channel activators and other antianginals.

   2. Antiplatelet therapy

   - Aspirin, P2Y12 receptor inhibitors, Glycoproteins IIb/IIIa inhibitors,

   3. Anti coagulant therapy :

   - Unfractionated Heparin, Anti-Xa inhibitors, Direct thrombin inhibitors,oral antithrombotics,

  4. Revascularization

​​​​​​ 5. Other considerations: CABG