Chest Pain / Angina Pectoris: Difference between revisions

Apart from starting medication the patient needs to minimize any present risk factors like smoking, overweight and drinking alcohol. ''See chronic coronary diseases''.

The procedure of PCI is similar to a CAG, except this time a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent that the effect of the balloon is only temporarily a stent is often positioned at the site of the stenosis.  

There are circumstances in which CABG should be performed.  

These numbers only account for the United States.  

A heart attack or myocardial infarction (MI) is an acute presentation of a process that has been going on much longer. The process responsible is atherosclerosis. Atherosclerosis is a chronic disease of the arteries in which artery walls thicken by deposition of fatty materials such as cholesterol. The result over decades are plaques, which can narrow the lumen of the arteries significantly and progressively causing symptoms as angina pectoris. Plaques can also suddenly rupture, trigger a cascade which results in a thrombus and thereby cause myocardial infarction.<cite>Davies3</cite>

Classic presentation of a myocardial infarction is acute chest pain which lasts longer than a few minutes.<cite>Swap</cite> The pain does not decrease at rest and is only temporarily relieved with nitroglycerin. Common accompanying symptoms are radiating pain to shoulder, arm, back and/or jaw.<cite>Foreman</cite> Shortness of breath can occur, as well as sweating, fainting, nausea and vomiting, so called vegetative symptoms. Some patients not really complain about chest pain but more about abdominal pain so as with angina pectoris the presentation can be very a specific.<cite>Canto</cite>,<cite>Pope</cite>

A suspected myocardial infarction should be rapidly evaluated to initiate appropriate therapy.  

On physical examination evidence of systemic hypoperfusion can be found such as hypotension, tachycardia, impaired cognition, pale and ashen skin.<cite>Antman</cite>

History and physical examination are helpful to determine myocardial infarction as diagnosis and to exclude other causes of chest pain, such as angina pectoris, aorta dissection, arrhythmias, pulmonary embolism, pneumonia, heartburn, hyperventilation or musculoskeletal problems.<cite>Antman</cite>

An electrocardiogram (ECG) should be made within 10 minutes of arrival in every patient with suspected myocardial infarction.<cite>Antman</cite>

An ECG is important to differentiate between myocardial ischemia and infarction:

Inferior wall ischemia - Leads II, III, and aVF  

Cardiac markers are essential for confirming the diagnosis of infarction. Elevated CK MB and Troponin I indicate damage of the myocardium. Cardiac Troponin I concentration begins to rise two to three hours after myocardial ischemia.<cite>Macrae</cite>

It can take 4-6 hours before the CK MB concentration is elevated. The advise is to repeat the measurements after 4-6 hours.<cite>Puleo</cite>

A pitfall concerning elevated Troponin I can be patients with renal failure or pulmonary embolism.<cite>Thygesen</cite> Although cardiac markers are helpful for confirming the diagnosis reperfusion should not always wait till the cardiac markers are known.  

Initial treatment of STEMI is relief of ischemic pain, stabilize the hemodynamic status and reduce the ischemia as quickly as possible by fibrinolysis or primary percutaneous coronary intervention (PCI). Meanwhile other measures as continuous cardiac monitoring, oxygen and intravenous access are necessary to guarantee the safety of the patient.<cite>Antman</cite>

* Patients with a non diagnostic ECG or a atypical history a coronary angiography with the ability to perform a PCI is preferred.<cite>VandeWerf</cite>

Fibrinolytics like streptokinase stimulate the conversion of plasminogen to plasmin. Plasmin demolishes fibrin which is an important constituent of the thrombus. Fibrinolytics are most effective the first hours after the onset of symptoms, after twelve hours the outcome will not improve.<cite>Bassand</cite>

Because re occlusion after fibrinolysis is possible patients should be transferred to a PCI qualified hospital once fibrinolysis is done.<cite>Silber</cite>

'''Table 3 Considerations for selecting primary percutaneous coronary intervention (PCI) for reperfusion therapy in patients with ST elevation myocardial infarction (STEMI)'''

The procedure of PCI starts off as a coronary angiography (see CAG). When the stenosis is visualized a catheter with an inflatable balloon will be brought at the site of the stenosis. Inflation of the balloon within the coronary artery will crush the atherosclerosis and eliminate the stenosis. To prevent that the effect of the balloon is only temporarily a stent is positioned at the site of the stenosis. To reduce the risk of coronary artery stent thrombosis antiplatelet therapy should be given.  

There are circumstances in which CABG should be performed.  

Patients with a score of 0 to 1 are at low risk, score 2 to 3 are at intermediate risk, score 4 to 6 are at high risk.

The main objective of in hospital conservative therapy is to relieve ischemic pain by intensifying medical therapy with aspirin and clopidogrel orally and nitro-glycerine, heparin and a beta blocker intravenously. If the patients becomes asymptomatic on these medication and is still asymptomatic when the medication is stopped, rest and stress imaging testing will be performed. The advantage of conservative therapy is reduction of the number of unnecessary revascularizations. The disadvantage is a prolonged stay in the hospital.  

Up to date: Trials of conservative versus early invasive therapy in unstable angina and non-ST elevation myocardial infarction, geen specifiekere bronvermelding.  

Rest and stress testing is indicated in patients with:<cite>Klocke</cite>

# Angina pectoris with ECG abnormalities during exercise ECG testing

MRI can be done with vasodilatory dobutamine or stimulating adenosine to assess how the heart behaves during exercise.<cite>Kwong</cite>

High risk patients, patients with persistent symptoms despite medication or a positive stress test need invasive therapy. Depending on what is seen during coronary angiography PCI or a CABG is indicated. (see PCI/CABG)

Fibrinolytic therapy is not used in NSTEMI.<cite>Ref2</cite>

Even though chronic coronary disease mortality rates have declined since 1970 it is still the leading cause of death in many western countries and in an increasing number of non western countries.<cite>Lloyd-Jones</cite>

A small amount of '''alcohol''' results in a lower risk of morbidity and mortality from coronary disease.  

Because extensive coronary disease can exist with minimal or no symptoms screening for coronary disease has been suggested. Although screening results in indentifying patients at increased risk there is lack of evidence that screening actually improves outcome.<cite>Gibbons</cite>