Coronary Heart Disease

• Fasting blood sugar / 2 hours post prandial / HbA1C.
• Lipid profile.
• Kidney function tests.
• CBC.
• Chest X ray could pick up rib fracture or dilated aortic root.

For NSTE-ACS patients (NSTEMI and UA):

• Constricting / heavy discomfort to the chest, jaw, neck, shoulders, or arms.
• Symptoms brought on by exertion, emotion, cold weather and heavy meals.
• Symptoms relieved within 5 min by rest or nitro-glycerine (GTN).
• Anginal pain usually lasts for less than 15 minutes.

The typical presentation is continuous severe retrosternal compressing anginal pain which occurs at rest, lasts for more than 20 minutes, and not relieved by rest or sublingual nitrates.

1. Typical angina.

1. Constricting / heavy discomfort to the chest, jaw, neck, shoulders, or arms.
2. Symptoms brought on by exertion, emotion, cold weather and heavy meals.
3. Symptoms relieved within 5 min by rest or nitro-glycerine (GTN).

To confirm the diagnosis of chronic coronary syndrome:

The typical presentation is continuous severe retrosternal compressing anginal pain which occurs at rest, lasts for more than 20 minutes, and not relieved by rest or sublingual nitrates.

• Association: typically associated with nausea, vomiting, and sweating.

• Attacks of anginal pain of increasing intensity, frequency, and duration (crescendo angina).
• New onset angina (de novo angina).
• Post infarction angina.
• Syncopal attacks as a complication.
• Acute dyspnea (acute heart failure).
• Cardiac arrest as a complication.

The outcomes of patients with ACS showed that the 30-day mortality rate is: 1.7% for patients with unstable angina (UA); 7.4% for patients with NSTEMI; 11.1% for those with STEMI.

Surface 12-lead Electrocardiogram (ECG): should be done as early as possible for the suspected ACS.

1. Opioids only in severe intolerable pain: e.g., morphine IV.
2. Immediate loading doses of antiplatelet drugs:
   • Aspirin: an initial daily dose of 300 mg, followed by a daily dose of 75 mg for life.
   • P2Y12 inhibitors: ticagrelor, loading dose of 180 mg followed by 90 mg twice daily for one year; or clopidogrel, 300 mg (600 mg if undergoing percutaneous coronary intervention (PCI)) loading dose, then 75 mg daily for one year.
   • Ticagrelor is preferred unless unavailable or contraindicated (patients in oral anticoagulants, advanced liver disease, and previous intracranial hemorrhage).
3. Loading dose of statin therapy:
   • 80 mg atorvastatin followed by daily dose of 80 mg for life;
   • OR 40 mg rosuvastatin followed by daily dose of 40 mg for life.
   • Target LDL for patients with acute coronary syndrome must be below 55 mg/dl with the maximum tolerated dose of statins with or without ezetimibe and PCSK9 inhibitors.
4. Intravenous nitroglycerin at 5-20 μg/min may help to control ischemic pain with close monitoring of blood pressure. Dose can be increased according to the blood pressure.
5. Anticoagulants: one of the following:
   • Unfractionated heparin.
   • Low molecular weight heparin.
   • Fondaparinux (fondaparinux is not used if the patient is to undergo PCI (risk of catheter thrombosis)).

Differential diagnosis of acute chest pain:

Risk factors of coronary atherosclerosis:

• Old age.
• Male gender.
• Sedentary life.
• Diabetes mellitus.
• Hypertension.
• Dyslipidemia.
• Smoking.
• Central obesity.

Anti-anginal drugs for symptom relief:

1. Short acting nitrates
   • Sublingual nitroglycerine or nitroglycerine spray.
   • Used during the attack of angina or shortly before exertion.
   • It is not recommended to give nitrates to patient on sildenafil to avoid profound hypotension and shock.
   • Nitrates work by: coronary vasodilation and increasing coronary blood supply; decreasing the O2 demand by decreasing preload (venodilatation) and afterload (vasodilatation).
2. Beta blockers or calcium channel blockers (non-dihydropyridines)
   • Both groups decrease contractility and heart rate with subsequent reduction in myocardial oxygen demand.
   • Target heart rate: 50-60 beat/min.
   • Selective B1 blockers are useful: carvedilol, bisoprolol, metoprolol.
   • Non DHP CCBs: verapamil and diltiazem.
   • Avoid betablocker in variant angina as it produces coronary spasm.
   • Avoid non DHP CCBs in heart failure with reduced systolic function as they worsen heart failure.

• Oral and transdermal patches are available.
• It is important to leave 8 hours nitrates free period to avoid nitrates tolerance.
• Headache is a common side effect that could be managed with paracetamol.

Revascularization with PCI (percutaneous coronary intervention) or CABG (coronary artery bypass graft) in the following indications:

1. Coronary stenosis > 90 % in one or more coronary arteries.
2. Coronary stenosis (50-90%) with one of the following:
   • Refractory angina.
   • Systolic dysfunction.
   • Positive noninvasive stress test.
   • Significant ischemia with invasive hemodynamic assessment.

Should be done as early as possible for the suspected ACS. It may show any of the following (changes must be present in 2 or more contiguous leads):

• ST elevation (≥1 mm) - pathological Q waves (if STEMI).
• ST segment depression.
• T wave inverted or biphasic.
• The presence of normal ECG does NOT exclude ACS if typical clinical picture is present and at this time follow up ECG, full investigation and monitoring should be done.
• Electrical complications e.g., atrioventricular block, supraventricular arrhythmias (including atrial fibrillation), ventricular tachyarrhythmias (ventricular tachycardia and ventricular fibrillation).

It should not delay revascularization in STEMI in acute setting. However, in acute setting, it is helpful in uncertain diagnosis and in patients with hemodynamic compromise. You could pick up:

• Evidence of new regional wall motion abnormality.
• Mechanical complications: mitral regurgitation - ventricular septal rupture.
• Other causes of chest pain e.g., aortic dissection, cardiac tamponade, pulmonary embolism.

It should not delay revascularization in STEMI in acute setting. However, in acute setting, it is helpful in uncertain diagnosis. You could pick up:

• Ischemic-related left-sided heart failure (pulmonary congestion).
• Clues about other causes of chest pain e.g., pneumothorax, aortic dissection, and pulmonary embolism.

• Elevated cardiac biomarkers (only in STEMI & NSTEMI, not in unstable angina) e.g., cardiac troponin, or CK-MB.
• Lipid profile should be obtained within 24 hours of the onset of ACS.
• Complete blood count: to exclude anemia and check for platelets.
• Kidney function test: to adjust medication doses.
• Glycated hemoglobin (HbA1C): to check for DM and if controlled.

1. Opioids only in severe intolerable pain: e.g., morphine IV.
2. Immediate loading doses of antiplatelet drugs:
   • Aspirin: an initial daily dose of 300 mg, followed by a daily dose of 75 mg for life.
   • P2Y12 inhibitors: ticagrelor, loading dose of 180 mg followed by 90 mg twice daily for one year; or clopidogrel, 300 mg (600 mg if undergoing percutaneous coronary intervention (PCI)) loading dose, then 75 mg daily for one year.
   • Ticagrelor is preferred unless unavailable or contraindicated (patients in oral anticoagulants, advanced liver disease, and previous intracranial hemorrhage).
3. Loading dose of statin therapy:
   • 80 mg atorvastatin followed by daily dose of 80 mg for life;
   • OR 40 mg rosuvastatin followed by daily dose of 40 mg for life.
   • Target LDL for patients with acute coronary syndrome must be below 55 mg/dl with the maximum tolerated dose of statins with or without ezetimibe and PCSK9 inhibitors.
4. Intravenous nitroglycerin at 5-20 μg/min may help to control ischemic pain with close monitoring of blood pressure. Dose can be increased according to the blood pressure.
5. Anticoagulants: one of the following:
   • Unfractionated heparin.
   • Low molecular weight heparin.
   • Fondaparinux (fondaparinux is not used if the patient is to undergo PCI (risk of catheter thrombosis)).

Time is muscle (reperfusion should start as early as possible).

Can be given in the first 12 hours of chest pain if Cath lab is not available. Then immediate transfer to a PCI capable center (streptokinase or better alteplase).

• Absolute contraindications
  • Haemorrhagic stroke or stroke of unknown origin at any time.
  • Ischaemic stroke in the preceding 6 months.
  • Central nervous system damage, neoplasms or structural vascular lesions (e.g. arteriovenous malformation).
  • Recent major trauma/surgery/head injury (within the preceding 3 weeks).
  • Gastro-intestinal bleeding within the last month.
  • Known bleeding disorder (excluding menses).
  • Aortic dissection.
• Relative contraindications
  • Transient ischaemic attack in preceding 6 months, dementia.
  • Oral anticoagulant therapy.
  • Pregnancy within 1-week post-partum.
  • Non-compressible punctures.
  • Traumatic resuscitation.
  • Refractory hypertension (systolic blood pressure >180 mmHg).
  • Advanced liver disease.
  • Infective endocarditis.
  • Active peptic ulcer.

• Is the preferred line of treatment in the 1st 24 hours after STEMI (could be done even within 48 hours after chest pain onset).
• Should be done if late presentation after 48 hours ONLY IF presented by electrical (arrhythmias) or mechanical (pulmonary edema or cardiogenic shock) complications.

• Coronary artery bypass surgery (CABG) if:
  • Multi-vessel coronary artery disease after opening of infarct-related artery with balloon dilatation.
  • Surgical repair of a mechanical complication (e.g., ventricular septal rupture).

• Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blockers (ARBs): for life for those with:
  • Hypertension.
  • Diabetes mellitus.
  • Anterior wall STEMI.
  • Reduced left ventricular systolic function.
• Beta-blockers for life with target heart rate in the ischemic patients (50-60 bpm at rest).
• Proton pump inhibitors if:
  • The patient on dual antiplatelet drugs in the first year after ACS.
  • Gastroesophageal reflux disease (GERD).
  • High risk for GIT bleeding.
  • History of peptic ulcer.
• Lifestyle modifications: the same as chronic angina.

Restoring sinus rhythm with DC shock regardless hemodynamics status.

1. Opioids only in severe intolerable pain: e.g., morphine IV.
2. Immediate loading doses of antiplatelet drugs:
   • Aspirin: an initial daily dose of 300 mg, followed by a daily dose of 75 mg for life.
   • P2Y12 inhibitors: ticagrelor, loading dose of 180 mg followed by 90 mg twice daily for one year; or clopidogrel, 300 mg (600 mg if undergoing percutaneous coronary intervention (PCI)) loading dose, then 75 mg daily for one year.
   • Ticagrelor is preferred unless unavailable or contraindicated (patients in oral anticoagulants, advanced liver disease, and previous intracranial hemorrhage).
3. Loading dose of statin therapy:
   • 80 mg atorvastatin followed by daily dose of 80 mg for life;
   • OR 40 mg rosuvastatin followed by daily dose of 40 mg for life.
   • Target LDL for patients with acute coronary syndrome must be below 55 mg/dl with the maximum tolerated dose of statins with or without ezetimibe and PCSK9 inhibitors.
4. Intravenous nitroglycerin at 5-20 μg/min may help to control ischemic pain with close monitoring of blood pressure. Dose can be increased according to the blood pressure.
5. Anticoagulants: one of the following:
   • Unfractionated heparin.
   • Low molecular weight heparin.
   • Fondaparinux (fondaparinux is not used if the patient is to undergo PCI (risk of catheter thrombosis)).

Time is muscle (reperfusion should start as early as possible).

Can be given in the first 12 hours of chest pain if Cath lab is not available. Then immediate transfer to a PCI capable center (streptokinase or better alteplase).

• Is the preferred line of treatment in the 1st 24 hours after STEMI (could be done even within 48 hours after chest pain onset).
• Should be done if late presentation after 48 hours ONLY IF presented by electrical (arrhythmias) or mechanical (pulmonary edema or cardiogenic shock) complications.

• Coronary artery bypass surgery (CABG) if:
  • Multi-vessel coronary artery disease after opening of infarct-related artery with balloon dilatation.
  • Surgical repair of a mechanical complication (e.g., ventricular septal rupture).

• Ischaemic heart disease: M.I.; angina pectoris.
• Pericardial disease: dry pericarditis; massive pericardial effusion.
• Massive pulmonary embolism and pulmonary infarction.
• Aortic dissection and aortic aneurysm.
• Cardiac neurosis:
  • Occurs in neurotic individuals.
  • Site: left inframammary and localized.
  • Radiation: no specific radiation (may be to left arm).
  • Character: stitching or stabbing.
  • No relation to exertion and no relief by rest.
  • Variable duration (seconds or hours).
  • Associated with local tenderness and may be other features of neurosis.
  • Normal cardiac exam.
• Huge cardiomegaly: may rarely cause retrosternal heaviness.
  • N.B. Huge left atrium: sawing pain (erosion of spine).
• Mitral valve prolapse, AS, AR.

• Examination is normal in most of cases.
• With ABCDE approach, you could pick up the cause of pain (cardiac or non-cardiac) or catastrophic complications for urgent management:

Surface 12-lead Electrocardiogram (ECG): should be done as early as possible for the suspected ACS.

1. Musculoskeletal (chest wall) pain.

• Pleuritic localized chest pain or that worse with swallowing is mostly non-ischemic pain.

1. Panic attacks (anxiety disorder).

Differential diagnosis of acute chest pain: