| Management of Angina involves 3
phases. 1. Assessment of the
severity of the problem.
2. Measures to control the symptoms.
3. Treatment to improve life expectancy.
Assessment of severity involves
general checkup and routine investigations to find out
any associated problem that might have precipitated or
helped in the progression of Coronary heart disease. Diabetes
mellitus or Hyperlipidaemia if
present have to be managed.
Severity of the disease is assesed
by Exercise Tolerance test Or Trendmill Test
commonly known as TMT.
Measures to contol the
symptoms:
Education of the patient regarding the cause of Angina - a
mismatch between coronary blood supply and the cardiac
need. Stress on the natural process of repair by the
development of anastomosis of small vessels to overcome
the reduced blood supply to a particular area. Patients
have to learn to help themselves by avoiding stressful
situations.
Advise to
patients of Angina
Avoid walking after
meals.
Avoid walking in cold particularly against wind.
Avoid unaccustomed exertion.
Stop Smoking
To maintain ideal weight.
To take regular exercise: exercise upto and not beyond
the point of chest pain is benificial.
Drug
Treatment
Nitrates
Beta Blockers
Calcium Antagonists
Nitrates
Glyceryl Trinitrate (GTN 500 micro gram)
taken under the tongue relieves pain within 2-3 minutes.
It should be spit out when the pain is relieved. It
causes slight headache. It can be put to best use by
taking it prophylactically before exercise or a
particular type of activity known to produce Angina.
Not more than 2 tablets per hour to be used. GTN shelf
life is short. Angina patients should be encouraged to
get use to increased amount of exercise. This helps in
the formation of collateral circulation in the cardiac
tissue.
GTN can also be given subcutaneously in the form of paste
or plaster which gives longer duration of action.
GTN is ineffective when swallowed.
Oral Nitrate are also available which have prolonged
action.
Isosorbide dinitrate 10 mg 3-6 per day.
Oral nitrate cause more headache which tend to reduce
with continuous use. Tolerance to nitrates occur and dose
needs to be increased. A nitrate free period of 1-2 hours
every 24 hours helps.
Long acting Oral Nitrate are also available which needs
to be given 12 hourly.
Beta blockers
It helps by reducing oxygen demand of the myocardial
tissue by reducing the heart rate for a given level of
exercise.
e.g. Propranolol, Atenolol, Metoprolol, Pindolol,
Oxprenolol,
Propranolol is lipid soluble and thus crosses blood brain
barrier and thus causes CNS side effects like drowsiness,
nightmares, depression. Atenolol is water soluble and
thus does not cause CNS side effects.
Beta
blocker drugs should not be withdrawn abruptly because of
risk of dangerous arrhythmias and myocardial infarction.
Calcium
antagonists
They inhibit slow inward current caused by the entry of
extracellular calcium through the cell membrane of the
excited cells. Their action is mainly in the arteriolar
smooth muscles and the atrial cells. The effect is
vasodilatation, reduction in excitability and
conductivity.
e.g. Nifedipine, Verapamil, Diltiazem,
Nicardipine.
Surgical
Treatment
Coronary Angioplasty
Bypass Grafting
Coronary
Angioplasty
This is performed by passing a fine guidewire across the
coronary stenosis under radiographic contoll. Using it a
baloon is positioned which is then inflated to dilate the
stenosis. It is mainly used in single or two vessel
disease.
Coronary
artery bypass grafting
This is done under cardiopulmonary bypass. Narrowed
segments od coronary artery are bypassed using grafts of
saphenous vein or the patients internal mammary arteries.
UNSTABLE ANGINA
Unstable angina is
anginal pain coming on at rest or on mininmal exertion.
It can be new phenomenon or be occur over the preexisting
stable angina. There are ST segment elevation or
depression at the time of pain but no parmanent ECG
changes occur.
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