Page 44 - Medicine and Surgery

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40 Chapter 2: Cardiovascular system

Newdevelopmentsincludepre-hospitaldiagnosisand Complications

thrombolysis by trained paramedics. Primary percu- Arrhythmiasmayoccurintheischaemicepisode(usually
taneous coronary intervention (i.e. angioplasty and heart block and ventricular tachycardia), and very rarely
stenting) has been shown to achieve lower mortality the ischaemia may result in myocardial infarction.
and earlier discharge following myocardial infarction.
It is of particular value in patients with contraindica- Investigations
tions to thrombolysis. It is not currently available in ECG shows characteristic ST elevation during an attack.
most hospitals in the United Kingdom. Glycoprotein
IIb/IIIa inhibitors are currently under evaluation. Management
Full mobilisation should be achieved after about 3 days Nitrates and calcium antagonists are useful as pro-
and discharge at 5 days, if there are no complications. phylaxis and as acute treatment. β-blockers tend to in-
Riskfactorsforcoronarydiseaseshouldbeidentifiedand crease coronary tone and hence exacerbate the angina.
modified where possible (stop smoking, lower serum It may be necessary to treat the arrhythmias provoked
cholesterol, control hypertension, diabetics should be by the spasm.
treated with insulin for 3 months). All patients should Surgical treatment is rarely necessary or possible.
be offered rehabilitation for physical and psychological
preparation for return to normal activities. The patient Prognosis
may return to work after 2–3 months, depending on the The prognosis in patients with angina without underly-
typeofwork.Cardrivingisnotpermittedfor4weeksand ing heart or metabolic disease is very good.
HGV and public service licences are withdrawn pending
evaluation.
If symptoms recur post-MI, or exercise tolerance test- Rheumatic fever and
ing shows continued myocardial ischaemia patients may valve disease
be referred for angiography with a view to angioplasty
or coronary artery bypass grafting.
Rheumatic fever
Prognosis Definition
50% 30-day mortality; 25% die before reaching hospital. Recurrent inflammatory disease affecting the heart; it
Of those who leave hospital alive, 15–25% die within the occurs following a streptococcal infection.
first year. Subsequent mortality is highly dependent on
age and comorbidity.
Incidence
1in 100,000 United Kingdom/United States population
peryear; incidence has declined over the last 100 years.
Variant/Prinzmetal’s angina
Definition Age
Angina of no obvious provocation not as a direct result First attack usually 5–15 years.
of atheroma.
Sex
Aetiology/pathophysiology M = F
Causedbyspasmofacoronaryarterymostoftenwithout
atheroma or in association with a mild eccentric lesion. Geography
The reason for spasm occurring is unknown. Common in Middle and Far East, South America and
Central Africa, declining in the West.
Clinical features
Pain is usually more severe and more prolonged than Aetiology
classical angina occurring at rest particularly in the early Cell-mediated autoimmune reaction following a pha-
morning. ryngeal infection with β-haemolytic streptococcus of