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Referral and warning signs
When to refer
URGENT hospital referral (H/RR) for ALL suspected ACS cases. Referral to cardiologist for: Diagnosis confirmation of stable angina (stress testing, angiography). Management of refractory angina despite medical therapy. Consideration for revascularization (PCI or CABG). Management of complications (HF, arrhythmias).
Red flags
- Chest pain suggestive of ACS (prolonged, severe, at rest, associated symptoms)
- Haemodynamic instability (hypotension, shock)
- Acute heart failure symptoms
- Significant arrhythmias
- New ST elevation or significant ST depression/T wave inversion on ECG
Signs and symptoms
- Stable Angina Pectoris: Episodic chest pain/discomfort/tightness/pressure, typically retrosternal, often radiating to neck/jaw/shoulder/left arm. Provoked by exertion or emotional stress. Relieved by rest or nitrates within minutes (<10-15 min).
- Acute Coronary Syndrome (ACS):
- - Unstable Angina: Angina occurring at rest, new onset severe angina, or increasing frequency/intensity/duration of previously stable angina.
- - Myocardial Infarction (MI / Heart Attack - NSTEMI or STEMI): Severe, prolonged (>20-30 min) chest pain/discomfort, often described as crushing/heavy. May occur at rest. Often associated with sweating (diaphoresis), nausea, vomiting, dyspnoea, anxiety, feeling of impending doom. Pain may NOT be relieved by rest or nitrates.
- - Atypical symptoms common in women, elderly, diabetics (e.g., dyspnoea, fatigue, epigastric pain).
- Sudden Cardiac Death (may be first presentation).
Risk factors
- Hypertension
- Diabetes Mellitus
- Dyslipidemia (High LDL, Low HDL, High Triglycerides)
- Smoking
- Family history of premature IHD
- Obesity
- Physical inactivity
- Male gender
- Increasing age
- Chronic kidney disease
- Chronic inflammatory conditions
Diagnosis
Clinical assessment
Diagnosis based on characteristic symptoms (chest pain description, triggers, relieving factors). Differentiate stable angina from ACS. Assess cardiovascular risk factors. Physical exam may be normal in stable angina; in ACS may show distress, pallor, sweating, tachycardia/bradycardia, S4/S3 gallop, new murmur (e.g., mitral regurgitation). Differential diagnosis: Non-cardiac chest pain (GERD, peptic ulcer, musculoskeletal, anxiety), Pericarditis, Aortic dissection, Pulmonary embolism.
Investigations
- ECG (12-lead):
- - Stable Angina: Often normal at rest; may show ST depression during pain or on stress testing.
- - ACS: ST elevation (STEMI), ST depression/T wave inversion (NSTEMI/Unstable Angina), or may be normal initially. Serial ECGs crucial.
- Cardiac Biomarkers (Troponin I or T): Key for diagnosing MI. Elevated levels indicate myocardial necrosis. Serial measurements needed (rise and fall pattern). Normal in unstable angina.
- Chest X-ray: Usually normal, rules out other causes, may show cardiomegaly/HF.
- Echocardiogram: Assess LV function, regional wall motion abnormalities, valvular function.
- Stress Testing (Exercise ECG, Stress Echo, Nuclear Stress Test): For diagnosing stable angina (induce ischemia). Contraindicated in ACS.
- Coronary Angiography: Gold standard to visualize coronary anatomy (stenosis). Used in ACS for diagnosis/intervention (PCI), or elective for severe stable angina.
Diagnostic criteria
Stable Angina: Typical symptoms relieved by rest/nitrates +/- positive stress test. ACS: Clinical presentation + ECG changes +/- elevated cardiac biomarkers (defines MI).
Management
Non-pharmacological management
- Lifestyle Modification (Crucial for all IHD): Smoking cessation, Healthy diet (low saturated/trans fat), Regular exercise, Weight control, Manage stress.
- Risk Factor Control: Aggressively manage hypertension, diabetes, dyslipidemia.
Pharmacological treatment
- Acute Coronary Syndrome (ACS) - Immediate Management (Hospital):
- - Aspirin 300mg chewed STAT (unless contraindicated).
- - Nitrates: Glyceryl trinitrate (GTN) sublingual/spray. IV infusion if ongoing pain/hypertension.
- - Oxygen: Only if SpO2 <94%.
- - Analgesia: Morphine 2.5-5mg IV titrated for severe pain.
- - Antiplatelet Therapy: Add second agent (e.g., Clopidogrel, Ticagrelor - depends on intended strategy [PCI vs conservative]).
- - Anticoagulation: Enoxaparin 1mg/kg SC BID (or UFH).
- - Beta-blocker: Oral BB (e.g., Metoprolol, Atenolol) within 24h if no contraindications (HF, shock, heart block).
- - Statin: High-intensity statin (Atorvastatin 40-80mg or Simvastatin 40mg) started early.
- - ACE Inhibitor/ARB: Start within 24h, especially if anterior MI, HF, or EF <40%.
- - Reperfusion Therapy (STEMI): Primary Percutaneous Coronary Intervention (PCI/angioplasty+stent) if available within timeframe (<90-120 min) OR Fibrinolysis (thrombolytic drugs) if PCI unavailable.
- Stable Angina - Chronic Management:
- - Risk Factor Modification Drugs: Aspirin 75-100mg daily, High-intensity Statin.
- - Anti-anginal Therapy (Symptom relief):
- - Beta-blockers (first-line).
- - Calcium Channel Blockers (Dihydropyridines like Amlodipine, or non-dihydropyridines like Verapamil/Diltiazem if BB contraindicated/not tolerated - avoid non-DHPs if poor LV function).
- - Nitrates (Short-acting GTN for acute relief; Long-acting nitrates like Isosorbide Mononitrate for prevention).
- - Other agents: Ivabradine, Ranolazine, Nicorandil (specialist use).
- - ACE Inhibitor/ARB: Recommended if hypertension, diabetes, CKD, or EF<40%.
Monitoring
- Monitor symptoms (frequency, severity of angina).
- Monitor BP, HR.
- Monitor lipids, glucose.
- Periodic ECG.
- Assess adherence and lifestyle changes.
Complications
- Myocardial Infarction (progression from unstable angina)
- Heart Failure
- Arrhythmias (Ventricular fibrillation/tachycardia, AF, heart block)
- Cardiogenic shock
- Cardiac rupture (ventricular wall, septum, papillary muscle)
- Ventricular aneurysm
- Pericarditis (Dressler's syndrome - late post-MI)
- Thromboembolism (mural thrombus)
- Sudden cardiac death
Prevention
- Primary Prevention: Control risk factors (BP, lipids, glucose, smoking, weight, exercise) in individuals without IHD.
- Secondary Prevention (After event/diagnosis): Aggressive risk factor control, Aspirin, Statin, Beta-blocker (post-MI), ACEi/ARB (if indicated).
Patient education
- Explain IHD, angina vs heart attack.
- Recognizing symptoms of ACS and seeking immediate help (call emergency services).
- How to use GTN spray/tablets for angina relief.
- Importance of lifelong medication adherence (Aspirin, Statin, etc.).
- Critical role of lifestyle changes (diet, smoking, exercise).
- Managing co-morbidities (BP, diabetes).
- Activity limitations and cardiac rehabilitation (post-MI/PCI/CABG).
Uganda-specific notes
Increasing prevalence due to lifestyle changes. Access to ECG, Troponin testing, Echocardiography, and especially PCI/Angiography/CABG is very limited. Management often relies on clinical diagnosis, risk factor control, and available medications (Aspirin, Statins, Nitrates, Beta-blockers, ACEi). Thrombolysis for STEMI may be an option in some centers if PCI unavailable.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 4, Section 4.1.7