The clinical case.
A patient is admitted to us and reports that he is suffering
from ischemic heart disease. We ask him if he had a heart attack but he denies.
however he reports having undergone PTCA and stenting intervention, in 2 different
sessions, for a symptomatology that arose for pre-established efforts. In
practice it happened that at a certain point of his working day (the patient was
a painter), after starting to work at a good pace, for about an hour, he accused
sweating with tiredness and a pain from the heart up to the jaw, with a feeling of weight in the
heart , so he had to stop, at least a good half hour before resuming work. The
cardiologist who was treating him, had advised him, in fact, a coronary
angiography that had been completed with stenting on D.A.
Elements for diagnosis: (1) typical stable angina symptoms: sternal constricting
or neck, or up to the jaw, one or both upper left limbs pain that arises as a result of
physical activity and ceases with rest or treatment with sublingual nitroglycerin or symptoms
of atypical stable angina: in these cases there is only one modality of the
onset or cessation of pain; (2) electrocardiographic changes: the ECG is almost
constantly observed to undergo ST segment subdivision during both the attack and
the stress test; (3) the frequency, severity and duration of symptoms have
remained unchanged for at least two months.
- Continuous or very prolonged
- Not correlated with motor activity
- Accentuated by respiratory acts
- Associated with vertigo, palpitations, tingling, difficulty with mastication
The most important clinical element is to exclude unstable angina which provides a diagnostic and therapeutic procedure of first urgency. When in doubt, especially in the new-onset angina, the patient should be hospitalized to be subjected to the necessary in-depth investigations. Useful exams: 1) Resting ECG: ST segment depression and T-wave inversion (but in more than 1/3 of the patients the ECG is normal). 2) Outpatient monitoring of the ECG (Holter examination) for any episodes of silent ischemia and / or arrhythmias. 3) Exercise ECG (for an assessment of doubtful cases). 4) Myocardial stress scintigraphy with Thallium 201: shows perfusion defects in patients with stress ECG of difficult interpretation or with an unenforceable test. 5) Echocardiography: demonstrates anomalies of myocardial wall contractility. 6) Echocardiography from pharmacological stress (mostly with dobutamine) in patients with unreliable stress ECG or ber seek the presence of hibernated myocardium. 7) Coronary angiography: patients with symptomatology resistant to treatment at full doses or in cases that remain doubtful after the use of non-invasive methods.
- The patient with a history of angina and acute episode in action must
immediately inform the doctor when an attack does not cease after taking three
tablets of nitro-derivatives sublingually.
- If the doctor is present, he must await the termination of the attack, given
the ever present risk of arrhythmic complications.
- Since nitro-derivatives (especially if they are at the first administration)
can sometimes give tachycardia and / or hypotension, with the risk of
accentuating angina, it is useful, at the first administrations, to repeatedly
check blood pressure and heart rate:
nitroglycerin (Trinitrine cf 0.30 mg). Pos: 1 cf sublingual repeatable every 5
min. Method of employment: the candy must be shattered in the mouth and kept in
the sublanguage; the patient must sit or lie down to avoid orthostatic phenomena.
or
isosorbide dinitrate (cpr 5 mg sublingual). Pos: 1 cpr per street
sublingual repeatable after 1-2 hours. Of such drugs one can also make a
prophylactic assumption before making an effort and even before a sexual
relationship if this generates angor. If the pain does not cease after 3
confetti hospitalize, taking care that medical care is present during the
transport phase of the patient.
Class I: symptoms occur only with unusual activities (minimal or no functional
involvement)
Class II: symptoms occur with prolonged or slightly more than usual activity (modest
functional involvement)
Class III: symptoms occur with usual activity (moderate functional involvement)
Class IV: symptoms occur at rest (severe functional involvement)
They are venous vasodilators that act at the cardiac level, both causing a
redistribution of the blood flow in favor of the ischemic areas, and reducing
the preload and the afterload. The route of administration significantly
differentiates the various formulations. The sublingual route is used in the
acute attack and before embarking on an activity capable of triggering the
attack. The effect occurs in a few minutes but its duration is rather short.
- The oral and transdermal pathways require significantly higher dosages then it
is necessary to saturate the degradation capacity of the liver. With this
formulations, stable blood levels are reached although tolerance may develop (see
side effects). To reduce the risk of developing tolerance for oral formulations,
asymmetric administration is recommended one hour before or two hours after
breakfast. lunch, avoiding evening administration. However, in night angina
patients an evening administration is required so that the drug-free interval
should be shifted during the day. For transdermal formulations, on the other
hand, the morning application of the transdermal system and the removal before
falling asleep is recommended, in order to prevent the establishment of a
tolerance state.
- The intravenous route (nitroglycerin ev Venitrin phlebo fi 5 mg]) allows an
immediate achievement of therapeutic levels even if there can be a noticeable
systemic hypotensive effect that requires near and electrocardiographic
monitoring. This formulation has proved to be useful in the treatment of
coronary vasospasm, Prinzmetal angina and acute pulmonary edema. Metabolism:
largely metabolised by the liver.
Half-life: nitroglycerin: 1-4 minutes. Isosorbide dinitrate 50 minutes.
Isosorbide mononitrate 5 hours.
Side effects: headache is frequent but often cedes after the first few days of
treatment. Other times a reduction of the doses or the suspension of the
treatment is required. Headache may initially be treated with aspirin or
paracetamol. Alternatively, treatment with tenitramine (Tenitran cpr 10 mg) may
give less or no headache. Less frequent are vertigo, restlessness, apprehension.
No rare hypotension, blurred vision, tachycardia, syncope. Isosorbide dinitrate
can give paradoxical bradycardia. Rare are contact dermatitis (transdermal forms)
and hot flashes. Methemoglobinemia with cyanosis in genetically deficient
subjects of methemoglobin reductase is very rare.
hypersensitivity, severe anemia. Use with caution in pregnancy, breastfeeding
and childhood. Tolerance occurs only in part of patients and predominantly in
those who take preparations that give stable plasma levels (prolonged oral forms
and patches). If it appears, the time of administration should be kept as far
apart as possible. It is generally sufficient to interrupt a few hours because
tolerance ceases. formulations
- Nitroglycerine cpr. Pos: 1 cpr sublingually repeatable every 5 min for 2-3
times.
- Transdermal nitroglycerin 5, 10, 15 mg. Pos: apply a patch for 12-14 hours.
Unless there is night angina the system should be applied early in the morning
and removed late at night.
Isosorbide dinitrate (cpr 5 mg sublingual). Pos: one cpr via Hublinguale
repeatable after 1-2 hours.
Isosorbide dinitrate cpr 10 mg. Pos: one CPR per os repeatable every 2-4 hours.
Isosorbide dinitrate cpr 20 and 40 mg. Pos: one CPR per os 2 \ ulte per day.
Isorhide mononitrate cpr 20 and 40 mg). Pos: one CPR 2-3 times a day.
Isorbide mononitrate cps r.p. 50 mg). Pos: one cps per day.
Effects of chronic treatment are those (1) to reduce the frequency and duration of attacks, (2) to improve exercise tolerance, (3) to reduce oxygen demand. The simultaneous correction of all other cardiovascular risk factors that may be present (hypertension, diabetes, hypercholesterolemia, smoking, reduced physical activity, obesity, etc.) is also fundamental. The cornerstone of angina maintenance therapy is made up of categories of drugs. associable as nitroderivatives, anti-aggregants, beta-blockers, calcium antagonists. Finally, any associated conditions capable of increasing oxygen consumption such as anemia, thyrotoxicosis, obesity, fever, infections, high heart rate must be identified and corrected.
All patients with chronic stable angina should be treated for at least 4 years
with acetylsalicylic acid at 75 mg / day unless there are clear
contraindications to the use of this drug. In this case it can often be replaced
by other antiplatelet agents. Valid alternatives to aspirin are ticlopidine,
clopidogrel, and other anti-blockers Betablockers
Beta-blockers remain first choice drugs in chronic ischemic heart disease
because they are effective, inexpensive, can be used once a day and are often
able to prevent arrhythmias, reinfection and sudden death; atenolol (Tenormin
cpr 100 mg): Pos: 50-200 mg / day, better still bisoprolol (from 1.25 up to 5
mg) (eg cardicor, sequacor etc.) and carvedilol (dilatrend 6.25 - 25 mg)
They are generally considered third-choice and are given in case of intolerance
to beta-blockers or added to patients in whom the above drugs have been
insufficiently effective. Calcium channel blockers should not be used
post-infarct because they have proved incapable of reducing mortality. There are
some important differences between the various calcium channel blockers used in
ischemic heart disease:
a) Verapamil and diltiazem have negative inotropic action, induce heart rate
induction, are also active in preventing arrhythmias. They are contraindicated
in heart failure, atrioventricular block and hypotension. The average daily
doses are for verapamil 80 mg 80-160 mg three times a day or for slow release
formulations 120 mg, 120-360 mg. For diltiazem cpr 60 mg) the average daily
doses' are 30-80 mg 4 times a day.
b) Generation II dihydropyridins such as nicardipine (Perdipine), felodipine,
amlodipine have poor negative inotropic action and can be used in angina even in
the presence of heart failure in association with diuretics, digitalis and ACE
inhibitors.
Nitrates
Oral nitrates are effective, with no serious side effects and should be used and
used if the beta-blockers are ineffective, insufficient or with troindicates (see
previous paragraph).
The association of nitroderivatives with beta-blockers is carried out in the exercise angina when the only beta-blockers were not sufficient. In this case the reflected tachycardia that the nitroderivatives often cause is also controlled. The association of calcium antagonists with beta-blockers can be carried out using dihydropyridines that have no significant negative inotropic action. However, verapamil and diltiazem should be avoided (to avoid a double negative inotropic and bradycarding action). The combination of nitroderivatives with calcium channel blockers may be particularly useful, using dihydropyridines, in individuals with heart failure or AV conduction problems. The combination of nitroderivatives, dihydropyridine calcium antagonists and beta-blockers may be useful in subjects with resistant angina.
Other drugs
The statins for their probable direct action on the plaque and on the
endothelium have become an indispensable garrison in the treatment of all cases
of stable angina. ACE inhibitors: they appear to exert a powerful protective
effect most likely on the endothelium of the myocardium for which they are
indicated in the treatment of angina. Finally, trimetazidine (Vastarel cpr 20 mg
Pos: 1 cpr three times a day) represents a further therapeutic option as it has
been shown to reduce the symptoms when added to patients with angina resistant
to beta-blockers or calcium antagonists. However, patients with angina
refractory to multiple antianginal drugs should normally undergo coronary artery
disease.
Revascularization is very often indicated for patients with angina refractory to standard medical therapy. In the subgroup with diseases of the left main or with disease of the three vessels with impaired ventri-linistra function, surgical treatment is the first choice option. The daughter-in-law documented that angioplasty (with or without stent implantation) would benefit me prognostically in patients with chronic stable angina.