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
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