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Treatment

Unstable Angina

Patients diagnosed with unstable angina (an acute coronary syndrome) are admitted to the hospital for immediate treatment. Underlying conditions (e.g., hypertension, fever) are identified and treated. Most cases of unstable angina can be stabilized within 48 hours with medication.

ECGs and blood tests are administered to rule out heart attack. In most cases, heart activity is monitored continuously using ECG to detect heart attack or arrythmias.

Unstable angina may be treated intravenously with heparin for 3 to 5 days. In some cases, injectable low-molecular-weight heparin may be used. Aspirin may be given at the same time or after heparin therapy. Heparin is an anticoagulant that inactivates factors involved in blood clotting.

Heparin medications include enoxaparin (Lovenox®), dalteparin (Fragmin®), and nadroparin (Fraxiparin®). Frequent blood tests are needed to monitor the concentration of heparin in the blood.

Patients with evidence of damaged heart tissue or significant changes on ECG may also receive intravenous administration of a IIb/IIIa inhibitor to dissolve existing blood clots and to prevent new clot formation.

A beta blocker is administered and a calcium channel blocker may be added if symptoms persist. Nitroglycerin may be given under the tongue or intravenously for severe or prolonged episodes of angina.

If symptoms of unstable angina persist despite medication, cardiac catheterization and coronary angiogram may be recommended. Information obtained during these procedures may indicate that primary PTCA or coronary bypass grafting (CABG) is needed.

Patients with unstable angina undergoing coronary angioplasty frequently are treated with IIb/IIIa inhibitors (anticoagulants) during the procedure and for 12 to 24 hours afterward.

The IIb/IIIa inhibitors almost completely prevent the formation of blood clots and may help dissolve existing blood clots. Available IIb/IIIa inhibitors include eptifibatide (Integrelin®), tirofiban (Aggrastat®), and abciximab (ReoPro®). Adding these agents to standard treatment regimens for unstable angina may reduce the risk for unstable angina progressing to heart attack.

Variant angina, a form of unstable angina, is treated with nitroglycerin, given both under the tongue (sublingually) and intravenously, and nifedipine, a calcium channel blocker.

Long-Term Therapy

Aspirin makes platelets less "sticky," decreasing the chances of blood clot formation. One 75 to 325 mg coated tablet daily is the typical dosage for chronic stable angina and unstable angina.

Studies have shown that some patients are resistant to the effects of aspirin therapy. Regular blood tests may be performed to monitor the patient's response; the results of these tests can be used to adjust the aspirin dosage or change the medication.

Clopedigrol (Plavix®), which is slightly more potent than aspirin, is considered a long-term alternative to aspirin therapy. Clopedigrol is usually taken in a dose of one 75 mg tablet daily.

Nitrates (nitroglycerin) are used to relieve angina and prevent the onset of angina when physical or emotional stress is anticipated. They dilate (open up) the coronary arteries and veins, which may increase blood flow to the heart, particularly the area receiving an insufficient blood supply.

Nitrates usually are administered as a small pill placed under the tongue, where it quickly dissolves and is absorbed into the bloodstream. Isosorbide dinitrate (Isordil®) is usually taken 3 times a day; isosorbide mononitrate (Ismo®, Imdur®) is taken either twice a day or once daily.

The most common side effects of nitrates are headache and flushing. In most cases, the headaches are not severe and occur less frequently or resolve over time. Some patients find the headaches intolerable and decrease the dosage or discontinue taking the drug.

Because tolerance to nitrates can develop quickly, combination therapy of a nitrate and a beta blocker or calcium channel blocker is commonly prescribed.

Beta blockers slow the rate at which the heart beats and weaken the contractions of the heart's chambers. This reduces strain on the heart and its need for oxygen.

Beta blockers commonly used include atenolol (Tenormin®), metoprolol (Lopressor®, Toprol XL®), nadolol (Corgard®), and propranolol (Inderal®). Most of these medications are taken once or twice daily.

Side effects (e.g., fatigue, dizziness) usually are mild and transient. The primary risk is reduced ability of heart muscle to contract and pump blood to the lungs for re-oxygenation (cardiac depression).

Calcium channel blockers dilate coronary arteries and veins, which increases blood flow to the heart. This allows the heart to pump blood more easily and decreases strain on the heart. Calcium channel blockers used to treat angina include nifedipine (Adalat®), diltiazem (Cardizem®), verapamil (Calan®, Covera®, Isoptin®, Veralan®).

Side effects include headaches, flushing, dizziness, and swelling (edema). Constipation has been associated with verapamil, especially in elderly patients.

Warfarin (Coumadin®) is an anticoagulant that is prescribed for patients who have a history of or are at risk for formation of blood clots (thrombosis).

Cholesterol-reduction therapy reduces the level of "bad" (LDL) cholesterol in the blood using medications called statins: atorvastatin (Lipitor®), cerivastatin (Baycol®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), and simvastatin (Zocor®).

Side effects are rare and include inflammation of the liver, and muscle pain and inflammation.

Underlying conditions associated with ischemic heart disease and angina, such as diabetes mellitus and hypertension, should be treated and closely monitored.

Other Treatment

Patients with chronic stable angina that is unresponsive to medical therapy may benefit from a relatively new treatment called enhanced external counterpulsation (EECP® therapy). EECP® therapy is a noninvasive outpatient procedure that can be performed in a physician's office. It usually is administered during 35 treatment hours, divided into one or two 60-minute treatment sessions per day, 5 days per week.

During treatment, the patient lies on a padded table and adjustable cuffs are wrapped firmly around the calves, lower thighs, and upper thighs. These cuffs are connected to inflation and deflation valves that are controlled by an electrocardiogram. When the heart rests, the cuffs are inflated sequentially and rapidly from the lower leg to the upper leg and then are deflated just before the heart beats. This results in an increased blood supply to the heart while reducing its workload.

EECP® therapy can reduce the symptoms of angina, decrease the need for medication, and improve the patient's quality of life. After treatment, many patients are able to exercise moderately for the first time since developing angina. In most cases, it takes 4 to 7 weeks of therapy to complete one course of EECP® treatment. Patients with extensive heart disease may require more than one course to achieve desired results. Side effects include minor skin irritation from the cuffs that are used and fatigue after the first sessions.

Angina, Treatment reprinted with permission from cardiologychannel.com
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