What is the fastest way to stop angina?

                                    Table of  content in fastest way to stop angina
1Different types of angina
2Stable angina: Clinical features, Phvsical examination / signs, Investigations, Therapeutic approach
3UNSTABLE ANGINA: Clinical features,Phvsical examination / signs, Investigations, Therapeutic approach
4PINZMETALS OR VASOPLASTIC ANGINA : Clinical features, Phvsical examination / signs, Investigations, Therapeutic approach
5Overall Therapeutic approach and FAQ

The fastest way to relieve angina is to immediately go on rest, leave work, and be admitted to a hospital. For the first-line treatment in emergency cases, nitroglycerin is given sublingually to the patient. Nitroglycerin should be given sublingually due to its rapid onset of action, direct go to systemic circulation, avoidance of first-pass metabolism, dose requirement, is less, highly lipid soluble and that’s why it is rapidly absorbed, and short duration of action.

Let’s know more about angina….

Angina can be defined as sudden, pressing, and severe chest pain that radiates to the left side of the neck and from the neck, it radiates into the right arms. It is known as angina. The most common cause of angina is due to reduce blood flow to the heart, which leads to ischemia.

There are three types of angina:

  1. STABLE ANGINA
  2. UNSTABLE ANGINA
  3. PINZMETALS OR VASOPLASTIC ANGINA

Stable angina:

It is known as a classical or typical angina pectoris. It is due to obstruction of the coronary arteries by atherosclerosis plaque. In this kind of angina, pain can be increase due to a heavy work load or begin to emotional with an incidence. The good part is a classical or stable angina can be relieved by using nitroglycerin, which is a potent vasodilator.

Management of stable angina / angina of effort:

Clinical features:

History:

 . Smoking.

 • Hypertension.

 • Diabetes.

 • Obesity.

 • Dyslipidemia.

 • Family history of coronary artery disease.

Symptoms:

 1. Central chest pain or discomfort or breathlessness.

 2. Precipitated by exertion or other forms of stress.

 3. Promptly relieved by rest or nitroglycerine.

Phvsical examination / signs:

1.Frequently negative.

Site & radiation of anginal chest pain.

2.Signs of risk factors (e.g. hypertension, diabetes).

3.Careful search for evidence of valve disease (particularly aortic).

4.Arterial disease (e.g. carotid bruits, peripheral vascular disease).

5.Left ventricular dysfunction (e.g. cardiomegaly, gallop rhythm).

6.Conditions that may exacerbate angina (e.g. anemia, thyrotoxicosis).

Investigations:

 1. Resting ECG: Reversible ST segment depression or elevation, with or without T-wave inversion. Features of previous MI may be found.

 2. Exercise ECG: Exercise-induced ST depression.

 3. Other forms of stress testing: Myocardial perfusion scanning ,Stress echocardiography

 4. CT coronary angiography.

 5. Direct coronary angiography: Detailed anatomical information about the extent and nature of coronary artery disease.

Unstable angina:

In this kind of angina, pain is aggressive and can spread rapidly. A person with less work may also develop this kind of severe pain.

Management of unstable angina:

Clinical features:

Symptoms:

 1. Chest pain, typically retrosternal, diffuse, radiates to the neck, jaw, shoulder, and arms.

 2. ”Angina equivalents” such as dyspnea and epigastric discomfort may also occur, and these appear to occur more often in women.

Signs:

 1. May be unremarkable.

 2. Evidence of atherosclerotic disease at other sites.

 3. May be sweating, pale cool skin, sinus tachycardia, and sometimes hypotension.

 4. May be hypertension.

 5. Signs to suggest anemia, thyrotoxicosis, hyperlipidaemia.

Investigations:

 1. ECG.

 2. Cardiac markers including troponin-I and T.

 3. Echocardiography.

 4. Exercise tolerance test.

 5. Coronary angiography.

 6. Investigations for risk factors e.g. blood sugar, lipid profile, renal function tests, CBC, thyroid

Prinzmetal angina or vasopastic angina:

This is a unique type of angina. This type of angina occurs at rest. Most importantly, pain does not reduce with taking rest. It mainly occurs due to spasms of the coronary arteries, which reduce blood flow to the heart, which is necessary for the normal pumping function of the heart. To improve this angina condition, doctors prescribe vasodilators such as dircet vasodilator (nitroglycerin) and calcium channel blockers.

Therapeutic approach of angina :

There are two processes to reduce the angina:

  1. To reduce the myocardial oxygen need

There are various mechanisms to reduce the myocardial oxygen demand, which are listed below :

  1. to reduce the extensive exercise
  2. decrease the preload of the heart
  3. decrease after  load of heart
  4. decrease the heart rate or frequency of heart pumping.
  5. coronary artery dilation, through which the blood can reach the heart and fulfil the heart’s demand for oxygen.
  1. increasing myocardial blood flow
  1. removal of the thrombus from the coronary artery by angioplasty.
  2. coronary artery bypass surgery, through which a bypass route can be formed in the heart to fuli fil the demand for oxygen by supplying the blood

The fastest and most effective way to stop angina is to use an antianginal drug :

There are many anti-anginal drugs. They are mainly classified into 6 groups.

  1. Nitroglycerin :

1.short-acting nitrolycerine: isosorbide dinitrate, glyceryl-tri-nitrate

2.long-acting: isosorbide mononitrate

Nitroglycerine causes coronary artery dilation: By Nitroglycerine releases nitric oxide, which causes vascular smooth muscle relaxation, which eventually causes the following events:

Nitroglycerine causes Vasodilation: decrease Venous return due to reduced peripheral resistance  – decrease preload; decrease intraventricular pressure of pumping blood – decrease cardiac function – decrease oxygen consumption; decrease anginal pain.

Pros and cons of using nitroglycerin:

use of nitroglycerine

  1. widely used in stable angina, unstable angina, and prinzmetal angina.
  2. myocardial infraction
  3. congestive cardiac failure

There are many adverse effects of using nitroglycerin.

  1. Throbbing type of headache
  2. Postural hypotensoin
  3. Tachycardia
  4. Nitrate tolerance

So nitroglycerine should only be used under the supervision of a medical person for example,  doctor, nurse.

  1. Calcium channel blockers are also very effective as antianginal drugs. They are very effective in treating angina as a treatment.
  2. Verapamil
  3. Diltiazem
  4. nifedipine
  5. Amlodipine
  1. Beta blockers block the beta receptors in the heart. Which reduced the heart rate. This causes less work by the heart, which reduces oxygen demand in the heart. And Release anginal pain.
  2. Propranolol
  3. Atenolol
  4. Metoprolol
  1. An antiplatelet drug has a thrombolytic action. it causes the breakdown of the platelet plug, which is blocking the coronary artery and preventing the blood supply to the heart. Antiplatelet drugs play an important role in antianginal treatment.
  2. Low dose of aspirin (75 mg)
  3. Clopidegrol

5. drug causes inactivation of clotting factor and inhibit platelet plaque formation.

  1. Heparin
  2. Low-molecular-weight heparin

FAQ

Qus: In which ward we should admit a patient with MI?
Answer : In CCU ward (not in ICU ward].

QUS: In which condition Morphine cannot be given?
Answer: In bronchial asthma & COPD we cannot consider Morphine.

QUS: When & how we give Inj. Streptokinase?
Answer: We give Inj. Streptokinase in a patient with ST-elevation & within 12 hours of best pain, in IV drip slowly (I.S million unit in 100 ml normal saline (@ 100 micro drops/min or over 1 hour).

If a patient comes 12 hours after pain, what will you give?
Answer: I will give low molecular weight heparin (LMWH) e.g. Enoxaparin 1 mg/kg body weight S/C 12 hourly for 8 days or upto discharge of the patient. The indications of LMWH are:
Non ST-elevated MI.
Non O-wave MI.
If the patient come 12 hours after the onset of chest pain.

Qus: What are the most common & important complications of streptokinase?
Answer: Common & important complications of streptokinase: Hypotension (so we should check frequertly i regularly during streplokinase therapy).
Bleeding manifestation.

Qus: How will you understand that streptokinase is working?
Answer: By seeing the ECG; reperfusion arrhythmia (idioventricular rhythm)

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