| ID | 69 |
|---|---|
| Name | UNSTABLE ANGINA |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigations: 1. ECG- during pain ECG may show ST depression or T wave inversion, sometimes transient ST elevation. 2. Raised levels of some specific intracellular cardiac enzymes (viz. Troponin T&I). |
| Management | Management: 1. Urgent hospitalization in coronary care unit (C.C.U). 2. General measures- a. Complete bed rest, b. Oxygen supplementation, c. Short-term sedation with diazepam may help. d. Maintenance of systolic pressure within 100-120 mmHg. and heart rate at 60/minute. 3. Glyceryl trinitrate- sublingual or oral preparation may be sufficient to subside unstable angina. If pain persists or recur, i.v infusion of nitroglycerin (0.6-1.2mg/h) or isosorbide dinitrate (l-2mg/h) should be started. 4. Anticoagulant/antiplatelet & thrombolytic treatment- a. Aspirin 75-325mg and/or clopidogrel 75mg daily should be started on admission, b. In high-risk cases heparin should be administered in i.v infusion or as subcutaneous low-molecular weight heparin (enoxaparin Img/kg 12 hourly). Heparin may be continued for 2 days if necessary, c. Glycoprotein Ilb/IIIA receptor may be a useful adjunct in unstable angina to block monoclonal antibodies to the platelets. 5. b-blockers- atenolol 50-100mg daily or metoprolol 50-100mg 12 hourly. 6. Calcium channel blockers- nifedipine or amlodipine can be added with (3-blocker. (Dose: see in the therapeutic section). 7. Most of the patients respond well with the above measures and can be gradually mobilized; and if no contraindication, after 3-4 weeks exercise testing can be arranged, & further management can be undertaken accordingly. But, if the above measures fail, or in cases of high-risk patients, they should be referred immediately for coronary angiography and further management accordingly. |
| Introduction | The term ‘unstable angina’ is used to describe a ‘severe angina’ usually starting at rest or with less exertion. The angina is rapidly worsening (Crescendo pattern angina), lasts longer and less responsive to medication. ECG & enzyme tests reflecting no evidence of significant myocardial infarction. This may present as a new phenomenon or with a background of chronic stable angina. On coronary angioscopy of this pattern angina, a high proportion of patients showed that, they have a ‘complex’ coronary stenoses characterized by plaque rupture, ulceration or haemorrhage with thrombus formation. This sometimes lead to complete occlusion of vessel and infarction. The ischaemic episodes are due to an abrupt reduction in coronary blood flow caused by thrombosis or spasm (supply-led ischaemia). But, stable angina, on the otherhand is related to a fixed obstruction of the vessel and is therefore precipitated by an increased myocardial oxygen demand (demand-led ischaemia) |
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