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Diabetologists in Doddabommasandra, Bangalore • Nitrates These useful drugs may be given in combination with beta-blockers or other anti-anginal treatment. There are a number of rapidly acting forms that can be used by a patient to obtain rapid relief of angina. In tablet form they dissolve rapidly under the tongue and should relieve angina within a few minutes. Anginine, which is available over the counter, can be broken in half. This may be useful for patients who experience side effects with a full tablet. However, they have a limited shelf-life (about three months once opened). Isordil is a similarly effective drug that lasts some years but is too small to be broken in half. There is also a prescription-only form available as a spray for sublingual use. It has a long shelf-life and is found by some patients to work a little more quickly than the tablets. These drugs may also be used prophylactically by those able to predict the onset of symptoms. Patients may need to be reassured that nitrates are not painkillers but relieve angina by helping the heart (by reducing myocardial wall stress). Patients must also be told that an increasing need for nitrates suggests a change in the severity of their angina and that their doctor should be informed of this. Response to sublingual nitrates may be helpful for diagnosis of chest pain. Rapid relief (within a few minutes) is suggestive of angina, but slower relief less so. Oesophageal spasm may also, however, be relieved by nitrates. Long-acting nitrates are readily available and are a useful adjunct to the treatment of angina. Nitrate patches have the advantage that the patient can place the patch close to the heart on the chest wall. This may have a reassuring feel about it. In fact they are equally effective placed anywhere on non-hairy skin. Because tolerance to nitrates develops and dissipates within hours, there should be a period of eight hours when the patient is not exposed to them (a nitrate-free interval). Usually the patient is advised to remove the patch before going to bed. If, however, the angina is usually worse at night, putting the patch on before bed and removing it during the following day may be the best approach. Oral long-acting nitrates are similarly effective. They are designed to ‘run out’ after 16 hours or so and therefore have a built-in nitrate-free interval. For this reason, they should be used only once a day. Nitrates have the advantage that larger doses give further therapeutic benefit as long as side effects are not intolerable. A dose of 120 mg or even more isorbide mononitrate or equivalent may be given daily. Nitrate side effects relate mostly to their vasodilator action. Headache is the most common problem and patients must be warned of this. If the patient persists with the drug and uses simple analgesics for the headache, tolerance usually develops after a few days. The drugs are best introduced at low doses; a small patch or half an isorbide mononitrate tablet. Nitrates do not impair ventricular function and the dose is not limited by this in the way that beta-blockers and calcium antagonists are. The short-acting nitrates can also cause headache and sometimes postural hypotension. Patients should be warned to sit down when using them. The patches can cause skin irritation in some patients.
Diabetologists in Doddabommasandra, Bangalore • Nitrates These useful drugs may be given in combination with beta-blockers or other anti-anginal treatment. There are a number of rapidly acting forms that can be used by a patient to obtain rapid relief of angina. In tablet form they dissolve rapidly under the tongue and should relieve angina within a few minutes. Anginine, which is available over the counter, can be broken in half. This may be useful for patients who experience side effects with a full tablet. However, they have a limited shelf-life (about three months once opened). Isordil is a similarly effective drug that lasts some years but is too small to be broken in half. There is also a prescription-only form available as a spray for sublingual use. It has a long shelf-life and is found by some patients to work a little more quickly than the tablets. These drugs may also be used prophylactically by those able to predict the onset of symptoms. Patients may need to be reassured that nitrates are not painkillers but relieve angina by helping the heart (by reducing myocardial wall stress). Patients must also be told that an increasing need for nitrates suggests a change in the severity of their angina and that their doctor should be informed of this. Response to sublingual nitrates may be helpful for diagnosis of chest pain. Rapid relief (within a few minutes) is suggestive of angina, but slower relief less so. Oesophageal spasm may also, however, be relieved by nitrates. Long-acting nitrates are readily available and are a useful adjunct to the treatment of angina. Nitrate patches have the advantage that the patient can place the patch close to the heart on the chest wall. This may have a reassuring feel about it. In fact they are equally effective placed anywhere on non-hairy skin. Because tolerance to nitrates develops and dissipates within hours, there should be a period of eight hours when the patient is not exposed to them (a nitrate-free interval). Usually the patient is advised to remove the patch before going to bed. If, however, the angina is usually worse at night, putting the patch on before bed and removing it during the following day may be the best approach. Oral long-acting nitrates are similarly effective. They are designed to ‘run out’ after 16 hours or so and therefore have a built-in nitrate-free interval. For this reason, they should be used only once a day. Nitrates have the advantage that larger doses give further therapeutic benefit as long as side effects are not intolerable. A dose of 120 mg or even more isorbide mononitrate or equivalent may be given daily. Nitrate side effects relate mostly to their vasodilator action. Headache is the most common problem and patients must be warned of this. If the patient persists with the drug and uses simple analgesics for the headache, tolerance usually develops after a few days. The drugs are best introduced at low doses; a small patch or half an isorbide mononitrate tablet. Nitrates do not impair ventricular function and the dose is not limited by this in the way that beta-blockers and calcium antagonists are. The short-acting nitrates can also cause headache and sometimes postural hypotension. Patients should be warned to sit down when using them. The patches can cause skin irritation in some patients.
THE BEST CARDIOLOGISTS IN YELAHANKA nvestigations of possible or probable stable angina Electrocardiography A standard 12-lead ECG should be obtained in all patients. This is likely to be normal in almost half of patients with subsequently proven coronary artery disease. Nevertheless, an abnormal trace lends weight to the symptoms and favours further investigation. Chest X-ray Routine radiology is not essential but may reveal important co-morbidities. It should always be performed in those with clinical evidence of hypertension, pericarditis (p. 174), heart failure or valvular disease, if only as a baseline. It is similarly indicated for patients with suspected or known pulmonary or systemic disease such as rheumatoid arthritis, COPD or alcoholism. Routine blood tests All patients with suspected angina should have the following routine investigations at presentation (NHF grade A recommendation): n fasting lipids, including total cholesterol, LDLs, HDLs and triglycerides—risk factors n fasting blood sugar—risk factor n full blood count—anaemia exacerbates angina n serum creatinine—impaired renal function is a risk factor and can be worsened by some cardiac investigations. If indicated clinically, thyroid function
SAMIKSHA HEART AND DIABETIC CARE IN YELAHANKA Echocardiographic findings in certain cardiac abnormalities It is important to be aware that modern colour flow mapping is so sensitive that small amounts of regurgitation are often detected from quite normal valves. Deciding whether these jets are significant can be difficult and requires experience. Mitral stenosis Thickening and doming of the mitral valve leaflets is visible on M mode and 2D scanning , It may be possible to measure the valve area by planimetry . Secondary changes such as left atrial size and the presence of rheumatic disease of other valves can be seen. Doppler interrogation of the jet of blood entering the left ventricle through the mitral valve will enable estimation of the valve area by a formula called the pressure half-time equation This will usually give accurate and consistent estimates of the valve area and is especially useful for serial measurements over months or years. It will also be possible to detect associated mitral regurgitation with Doppler. Mitral regurgitation and mitral valve prolapse Here the mitral valve may appear normal and abnormal co-aptation of the leaflets is not usually visible . The left atrium will appear enlarged if significant chronic MR is present, and if this is severe left ventricular dilatation will be present. If the MR is due to mitral valve
HEART DOCTORS IN YELAHANKA NEWTOWN, BANGALORE Management of ACS (NSTEACS) Patients with this diagnosis represent a rather heterogeneous group. Some have had the recent onset of angina at the extremes of exercise, others have angina at rest associated with ECG changes. This variation has made attempts to study the effects of different treatment rather difficult. Although the majority of patients with myocardial infarction have a preceding period of unstable angina, only about 5% of all patients admitted to hospital with a diagnosis of an ACS go on to infarct during that admission. The in-hospital mortality for these patients is low. Mortality rates of less than 2% are usual. Nevertheless, there is a real short-term and longerterm risk of infarction, recurrent admission with unstable symptoms and death which is higher than that of patients with stable angina. The diagnosis should therefore lead to admission to a CCU. The cardiac enzymes are, by definition, not elevated in these patients but the newer, more sensitive tests for troponin T and troponin I may be abnormal and indicate a worse prognosis . In the CCU, bed rest, oxygen and ECG monitoring are routinely enforced and any mobile phones taken away (allegedly to protect the monitoring equipment). Recurrence of chest pain can be assessed quickly and ECGs performed to look for changes suggesting infarction. The cardiac biomarkers can be checked regularly. All patients should receive aspirin (300 mg) unless there is a contraindication. Patients with an intermediate or a higher risk should also be given clopidogrel (usually a 300–600 mg loading dose). The use of intravenous heparin has become standard treatment. A typical starting dose is 5000 units as a bolus followed by 24, 000 units over 24 hours. The activated partial thromboplastin time (APPT) should be measured after about six hours of treatment and the infusion rate of heparin adjusted to maintain this at about twice normal. Heparin is generally safe when used in this way. Bleeding problems may sometimes occur and the platelet count should be checked every few days so that heparin-induced thrombocytopenia (HITS), a rare but serious complication, can be detected early. Low molecular weight heparins are at least as effective as unfractionated heparin. These drugs have some advantages over heparin. Their dose response effect is more predictable and they cause less thrombocytopenia. They are effective given subcutaneously without APPT monitoring and are now cheaper than IV heparin when savings on APPT monitoring and the use of infusion sets are considered. A standard twice-daily dose is given according to the patient’s weight—1 mg/kg for enoxaparin (Clexane). The dose is reduced by half for those with moderate or severe renal impairment and for those over the age of 75. Additional treatment should include beta-blockers unless these are contraindicated. These drugs reduce the number of ischaemic episodes and probably the risk of myocardial infarction. Nitrates can be a useful adjunctive treatment. They may be given orally, topically or intravenously. The IV dose can be titrated up or down depending on the amount of pain the patient is experiencing and the severity of side effects such as hypotension and headache. The problem of tachyphylaxis with nitrates can be overcome by steady increases in the IV dose if necessary. Calcium antagonists are appropriate treatment for patients intolerant of beta-blockers and may sometimes be added to beta-blockers. Nifedipine, especially in its short-acting form, should not be used for patients with acute coronary syndromes unless they are already taking beta-blockers. Thrombolytic drugs have been disappointing when used for NSTEACS. In trials where they have been used for patients with ischaemic chest pain but without ST elevation there has been a trend towards an adverse outcome. This may be related to the rebound hypercoagulable state that can occur after their use. In general they should not be used for the treatment of NSTEACS. Glycoprotein IIb/IIIa inhibitors (p. 198) should be given for high-risk patients,
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