Acute Coronary Syndromes and Stable

Angina

Written by Faiza Khan MPharm MSc

Delivered by Zahraa Jalal MSc. CPIPP, FHEA, PhD-

Candidate.

Objectives

• Define Acute Coronary Syndrome

• Understand the epidemiology and aetiology of

- Myocardial infarction (ST and Non ST elevated)

- Unstable Angina

• Understand what stable angina is

- Describe the treatment options available

Acute Coronary Syndrome

“Refers to any group of symptoms attributed to the

obstruction of the coronary arteries”

This includes;

•Non ST elevated Myocardial Infarction

•ST elevated Myocardial Infarction

•Unstable Angina

Myocardial Infarction

• Also known as a ‘Heart Attack’

• Defined using a rise in the cardiac enzyme

troponin

• This enzyme is increased when cells are

damaged

• It is best measured 12 hours after pain as it is

released slowly

Myocardial Infarction: 2 types

ST elevated

• This means there is an

elevation on the ST

segment of a 12 lead

ECG

Non ST elevated

• There is no change in the

12 lead ECG

The statistics

• 600 per 100,000 men between ages 30-69

• 200 per 100,000 women of same age

• That is: 91,000 heart attacks per year in men and

31,000 women

• Total mortality was 101,000 deaths in 2005 from

CHD

• Death rates are higher in the first few hours after a

cardiac event

Causes

• Formation of an atherosclerotic plaque

• This can cause cell death

• Stable plaques can cause arterial blood flow

obstruction and symptoms of angina

• Unstable plaques are prone to rupture and can

form a thrombus

• If a vessel is completely occluded it can lead to a

NSTEMI

• View:

https://www.youtube.com/watch?v=EmB95sPHlkc

Risk factors

Modifiable

• Tobacco smoke

• High cholesterol

• High blood pressure

• Physical inactivity

• Obesity

• Diabetes

Non-modifiable

• Increased Age- 83% that

die are over 65 yrs

• Male sex

• Family history

• Race

Symptoms

• Sudden onset ‘crushing’

chest pain

• Originates in the centre of

the chest the radiates to

the arms, neck or jaw

• Associated with sweating

and shortness of breath

• Can be difficult to

distinguish between heart

related chest pain and

GORD

Other symptoms

• Anxiety

• Light-headedness with or without syncope

• Cough

• Nausea with or without vomiting

• Wheezing

Treatment of ST elevation MI

• Aspirin

• Coronary reperfusion therapy

- Either primary percutaneous coronary intervention

(PCI) with additional antiplatelet agent e.g.

ticagrelor or prasugrel

- Or fibrinolysis e.g. alteplase, tenecteplase,

streptokinase

• Coronary angiography

• Medical management and secondary prevention

• Pain relief, anti-emetics and glycaemic control

Ticagrelor

• PCI and medical management

• ADP receptor antagonist

• Side effects – bradycardia, breathlessness

• CYP 3A4 interactions, statins

• PLATO - 16% reduction in end point with 9% increased risk of bleeding

• Advantage may lie in faster onset of action

Prasugrel

• Prasugrel – Triton TIMI 38

• Mode of action identical to clopidogrel

• Superior to clopidogrel with increased risk of

bleeds

• Advantage may lie in faster onset of action

• NICE – use in pPCI, stent thrombosis with

clopidogrel, diabetes

Secondary Prevention of STEMI

• Aspirin at low dose lifelong

• If patient has had a stent dual antiplatelet therapy may be

required (clopidogrel)

• Ticagrelor may be used in combination with low-dose

aspirin is recommended for up to 12 months

• PPI (lansoprazole) may be required to reduce GI side

effects

• Beta blockers can reduce mortality after MI

• Lipid lowering treatment

• ACE inhibitors e.g. ramipril started 24-48 hours post MI

with aim to titrate dose within 4-6 weeks post discharge

• Aldosterone antagonists e.g. epleronone may be offered to

patients with heart failure post MI

Unstable Angina

• Angina is a condition marked by crushing pain in your

chest that may also be felt in your shoulders, neck, and

arms

• The pain is caused by inadequate blood supply to your

heart, which leaves your heart deprived of oxygen.

• Unstable angina is chest pain that happens suddenly and

becomes worse over time

• It occurs seemingly without cause—you may be at rest or

even asleep. An attack of unstable angina may lead to a

heart attack. For this reason, an attack of unstable angina

should be treated as an emergency, and you should seek

immediate medical treatment

Unstable Angina

• If a patient presents with symptoms of MI but not a

sufficient troponin rise

• Or no troponin rise

• They may or may not have changes on their ECG

• They are then termed as having unstable angina

Treatment of NSTEMI and Unstable Angina

• Aspirin – loading dose of 300mg

• Clopidogrel – 300mg

• Consider eptifibatide and tirofiban in patients who

will undergo coronary angioplasty or abciximab as

an adjunct to PCI

• Antithrombin therapy with either fondaparinux or

unfractionated heparin

• Coronary angiography with or without PCI or

coronary artery bypass graft (CABG)

• Pain relief and anti-emetics

Secondary prevention of NSTEMI and

Unstable Angina

• Aspirin and clopidogrel antiplatelet therapy

• Anti-anginal therapy: isosorbide mononitrate,

calcium channel blockers and nicorandil

• Lipid lowering medication

• ACE inhibitors

Cardiac rehabilitation

• This should be offered to patients soon after

cardiac event

• The benefits of the program should be highlighted

• Should start within 10 days of discharge from

hospital

Lifestyle changes

• Advise patients to eat a Mediterranean style diet

(more fruit, bread, vegetables and fish)

Lifestyle changes

• Advise patients to be physically active for 20-30

minutes a day to the point of slight breathlessness

or start at a level that is comfortable

• Advise patients on smoking cessation

• Weight management

• Alcohol consumption to normal limits

Stable Angina

• Angina is pain or constricting discomfort that typically

occurs in the front of the chest but may radiate

• Brought on by physical exertion or emotional stress

• Some people can have atypical symptoms, such as

gastrointestinal discomfort, breathlessness or nausea

• Angina is the main symptom of myocardial ischaemia and

is usually caused by atherosclerotic obstructive coronary

artery disease restricting blood flow and therefore oxygen

delivery to the heart muscle

• Stable angina does not typically occur more frequently or

worsen over time

Stable Angina

• Stable angina is a chronic medical condition with a

low but appreciable incidence of acute coronary

events and increased mortality

• The aim of management is to stop or minimise

symptoms, and to improve quality of life and long-

term morbidity and mortality

• Management options include lifestyle advice, drug

treatment and revascularisation using

percutaneous or surgical techniques

Treatment

• Short acting nitrate

• Use before planned exertion

• Flushing, headache and light-headedness may

occur

• If pain does not go after repeating dose after 5

minutes call ambulance

Secondary prevention of cardiac events

• Aspirin 75mg daily

• ACE inhibitors for people with stable angina and

diabetes

• Statin therapy

• Hypertension treatment

• Dietary supplements such as vitamin or fish oil

have no evidence in helping angina

• Beta blocker or calcium channel blocker as first

line or combination of two if required

Beta blockers in stable angina

• First line treatment

• Reduce rate and force of contraction and reduce arterial blood pressure

• Improve coronary perfusion during diastole – improve myocardial blood supply

• Antiarrhythmic action

• Antihypertensive action

• Reduce frequency and severity of attacks

• Reduce risk of MI

Beta blockers in stable angina

• Shown to be at least as effective as other anti-

anginals

• Reduce risk of first infarction in angina

• Reduce risk of re-infarction following MI

• Most episodes of angina have associated

tachycardia – antiarrhythmic benefit

Calcium Channel Blockers

• Dihydropyridines and non-dihydropyridines

• Peripheral vasodilation

• Coronary vasodilation

• Reduce rate and force of contraction

Calcium Channel Blockers

• Shown to more effective than placebo, as effective

as beta-blockers

• Post MI evidence lacking

• First line where beta-blocker not appropriate

• M/R agents preferred

• Suitable combination therapy

• Side effects – constipation, headache, flushing,

swollen ankles, bradycardia

Anti-Anginals

• Should not be used first line

• If first line treatment not tolerated;

• a long-acting nitrate or

• Ivabradine or

• Nicorandil or

• Ranolazine as monotherapy

• If not controlled with first line treatment one of these can

be added

• Consider adding a third anti-anginal drug only when the

person's symptoms are not satisfactorily controlled with

two anti-anginal drugs

Nitrates

• Mimic endogenous NO causing vasodilation

• Improve coronary blood flow, reduce preload and afterload

• Protect against exercise induced ischaemia

• Little outcome data

• Short acting vs. long acting

• Tolerance

• Adjunctive therapy, not monotherapy

• Side effects - headache

NITRATES- Adverse effects Nitrates

The most common adverse effect of nitroglycerin, as well as of the other nitrates, is Throbbing headache.

From 30 to 60 percent of patients receiving intermittent nitrate therapy with long-acting agents develop headaches.

High doses of nitrates can also cause postural hypotension, facial flushing, and tachycardia.

Nitrates are contraindicated if intracranial pressure is elevated

Warning !!!

Sildenafil (viagra) (PDE-5 inhibitors), tadalafil and vardenafil, potentiate the action of the nitrates. To preclude the dangerous hypotension that may occur, this combination is contraindicated.

NITRATES-Tolerance

• Tolerance to the actions of nitrates develops rapidly.

• The blood vessels become desensitized to vasodilation.

• Tolerance can be overcome by providing a daily (nitrate-free interval) to restore sensitivity to the drug.

• This interval is typically 10 to 12 hours, usually at night, because demand on the heart is decreased at that time.

• Nitroglycerin patches are worn for 12 hours then removed for 12 hours.

Nicorandil

• Potassium channel activator – relaxes vascular

smooth muscle

• Reduces frequency of episodes

• IONA data

• Give 12 hourly for 24 hour cover

• Used as monotherapy and adjunct

• Less effect on BP

Ivabradine

• Inhibitor of If channel in SA node

• Reduces resting heart rate

• Shown to be superior to placebo, non-inferior to

atenolol and amlodipine

• Weak P450 enzyme inhibitor

• Side effects – visual disturbances, bradycardia

• Place in therapy?

Ranolazine

• Mode of action largely unknown

• Inhibits late sodium current, decreases sodium

accumulation, decrease calcium overload

• Expected to improve myocardial relaxation and

reduce diastolic stiffness

• No effect on BP, heart rate

Ranolazine

• No mortality data, some morbidity

• Start 375mg bd increasing to 500mg bd then

750mg bd after 2-4 weeks

• Stop if ineffective

• Side effects – dizziness, nausea, vomiting

• CYP3A4 interactions

• Place in therapy?

Other interventions

• Consider revascularisation (coronary artery

bypass graft [CABG] or percutaneous coronary

intervention [PCI]) for people with stable angina

whose symptoms are not satisfactorily controlled

with optimal medical treatment

Questions

References

• http://sign.ac.uk/pdf/sign93.pdf : Acute coronary

syndromes

• Nice guideline CG 48: MI – secondary prevention:

Secondary prevention in primary and secondary care for

patients following a myocardial infarction

• Nice guideline CG 167: Myocardial infarction with ST-

segment elevation: The acute management of myocardial

infarction with ST-segment elevation

• Nice guideline CG 94:Unstable angina and NSTEMI: The

early management of unstable angina and non-ST-

segment-elevation myocardial infarction

Acute Coronary Syndromes and Stable

Angina