He no longer has a pulse, but Dick Cheney has a mechanical heart pump – and a chance for a normal life.

The 69-year-old former vice president is back in action, albeit a little thinner.

"He really doesn't have a pulse, but he has blood pressure because blood is being pumped out from his ventricle into the aorta at a constant pressure," explains Dr. Kirk Garratt, clinical director of interventional cardiovascular research at Lenox Hill Hospital.

But what exactly is beating in Cheney's chest?

Called an implantable left ventricular assist device, it "works like a little centrifugal pump," Garratt said. "It is like a spinning motor that acts like a fan to draw blood out of the pumping chamber, or left ventricle, and it propels the blood into the aorta."

Cheney's device, which is almost like a partial artificial heart, is battery-powered.

Implanted in the patient's chest, the device is connected to a cable that comes out of the body and connects to a mini computer that plugs into a battery pack. The patient wears a vest that holds these in place, and spare batteries must be carried as well.

"With a normal heart, the left ventricle fills with blood and the muscles of the heart all squeeze at once to push the blood out in one quick wave," Garratt said. "The pressure of that blood being pushed out into the arteries is what you feel as a pulse when you put your fingers to your wrist. But the pump works continuously, always drawing blood out of the left ventricle and propelling it into the aorta at a constant rate. So you don’t generate a pulse."

Typically, the pump's batteries last for around six hours, and then they must be changed.

But why does Cheney no longer have a pulse?

The mechanical heart works continuously to push the blood, rather than mimicking a heartbeat.

But don't think that just anyone can get this heart pump. Getting a pump like Cheney’s is major surgery and can require a lengthy hospital stay and recovery time.

"It’s a big surgery that carries with it very real risks," Dr. Mathew Williams, surgical director of cardiovascular transcatheter therapies at NewYork-Presbyterian Hospital Columbia told the Daily News. "We tend to put them into people who are going to die without them."

Cheney will likely have this device in place for the rest of his life.

Some patients are given this mechanical heart until they are healthy enough for a transplant. But in older patients like Cheney -- who has had five heart attacks -- a heart transplant is not always an option.

“Hearts are an exceedingly rare commodity,” Garratt says. “It’s hard to make the decision to give a heart to a man who is [close to] 70 when you know that means a 30-year-old may not be able to get it.”

nydailynews.com

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Do you like to ring in the New Year with an icy dip in the Atlantic?

Taking a 'polar bear plunge' is more than just a cold shock to the skin – it's a shock to your entire system.

Brave souls who race to Coney Island each year to jump into frigid waters boast the plunge's invigorating qualities – After all, the Scandinavians have been diving into cold water and then warming up in the saunas since the time of the Vikings.

But does it really give your health a boost?

"I don't know of any definitive medical studies that have been done to measure the health benefits of cold-water swimming," Dr. Alan Steinman, one of the country's foremost experts on hypothermia and cold-water survival told Msnbc.com.

He's worried that these chilly revelers may be taking health risks.

He recommends a gentle dip, slowly into shallow water, rather than a total, sudden plunge. Yes, this sort of defeats the purpose for these daredevil human polar bears.

When the body is suddenly immersed in icy water, there's a sudden gasp, an inhalation, rapid breathing and the inability to hold your breath, "which can be a problem if your head's underwater," he says.

For that reason, it's better to "plunge" gradually, from shallow water, and not off a dock or a boardwalk. It's possible to go into cardiac arrest due to shock -- The small blood vessels constrict on the surface of your body as a defense mechanism, so you don't lose heat. That means that a whole lot more blood is being squeezed into the same amount of blood vessels, which "serves to increase the effect on blood pressure," said Steinman.

Still, organizers of the Maryland State Police Polar Bear Plungefest, which raises money for charity, has been incident-free.

Around 12,000 people are expected to run wild in the Chesapeake.

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Popping aspirin on a regular basis may cut your risk of dying from cancer.

People who took the over-the-counter drug for several years were 21% less likely to die of stomach, esophageal and lung cancers, according to a study in the journal Lancet.

When British researchers looked at eight trials in which more than 25,000 patients participated, they learned that two decades later, the risk of those patients dying from lung cancer fell 30%, the risk of dying from esophageal cancer decreased by 60%, and the risk of dying from colorectal cancer dropped 40%, according to U.S. News and World Report.

"This is important as a proof of principle that a single simple compound like aspirin can reduce the risk of cancer substantially," study author Peter M. Rothwell told The NY Times. "There's been a lot of work over the years showing that certain compounds can increase the risk of cancer, but it's not been shown before that we can reduce the risk with something as simple as aspirin."

Low doses of aspirin have been used for years by those who want to lower their heart attack risk. Still, experts warn, aspirin also can be risky. Those who take it on a daily basis have an increased chance of developing an ulcer and internal bleeding, for instance. In fact, a daily aspirin bumps up the risk of internal bleeding to one in every 2,000 to 3,000 people.

Dr. Michael Aziz, an internist at Lenox Hill Hospital and author of "The Perfect 10 Diet," feels that only diabetics and those at a high risk for heart attack or stroke should take aspirin on a daily basis.

"People are popping aspirin like it’s nothing," he says. "Yet long term aspirin use has been linked to health problems such as macular degeneration."

Another potential risk with a regular regimen of aspirin could be bleeding into the brain, or a hemorrhagic stroke.

In the study, researchers learned that the size of the aspirin dose did not appear to be all that significant. In most trials, participants got a low dose of 75 to 100 milligrams. The patients that had the most dramatic reduction in cancer deaths were those who were in the longest lasting trials.

So does this mean you should take an aspirin a day? "Many people may wonder if they should start taking daily aspirin, but it would be premature to recommend people start taking aspirin specifically to prevent cancer," American Cancer Society epidemiologist Eric J. Jacobs told The Times. "It’s hard to assess effects on mortality from just one study."

nydailynews.com

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An assistant professor of medicine, and associate director of the Mount Sinai Hospital echocardiography laboratory, Dr. Lori Croft is a cardiologist who specializes in pregnancy and the heart.

Who's at risk

Although pregnancy causes no cardiac problems for the vast majority of women, certain groups of women have an ­elevated risk of heart complications during pregnancy.

"A woman who has a history of heart disease, heart murmur, rheumatic fever or high blood pressure is potentially at risk during pregnancy," says Croft. "If you fall into one of these groups, you should talk with your doctor before becoming pregnant."

Overall, less than 1% of pregnancies are complicated by heart disease.

"Far and away the majority of women will have no cardiac issues and will not need to see a cardiologist during pregnancy," says Croft. "However, though rare, heart problems when present can affect anyone — age and ethnic background aren't a factor."

In particular, women with certain complex congenital heart problems have an elevated risk. "For some rare conditions, pregnancy is not advised at all," says Croft.

In a very small number of cases, previously asymptomatic women discover they have a heart defect when it shows symptoms for the first time due to the additional stress of pregnancy.

There are three heart-related conditions that are most likely to develop in otherwise healthy women during pregnancy: heart murmur, arrhythmia and hypertension.

"Women often develop a murmur from the extra blood flow in the heart, but only rarely is it pathologic," says Croft. "An arrhythmia is a heartbeat that may be too fast or too slow, regular or irregular, and usually no treatment is required."

The most common cardiac complication during pregnancy is hypertension, or high blood pressure. "This affects about 8% of all pregnancy women, most often after the 20th week," says Croft.

"High blood pressure during pregnancy can affect the supply of oxygen to both the mother and the baby, putting them both at risk," she says. If you develop hypertension during pregnancy, the most serious form it can take is pre-eclampsia, which requires immediate attention because it can be life-threatening. Certain risk factors place you at increased risk of developing hypertension during
pregnancy and pre-eclampsia.

Those most at risk are first-time mothers, women carrying multiple babies, teenage mothers, women older than 40 and women who had high blood pressure or kidney disease before pregnancy.

Signs and symptoms

Pregnancy is a physiological state that places a burden on the heart. "The heart has to work harder for nine months," says Croft. "A pregnant woman's heart pumps 30%-50% more blood than before pregnancy."

While a healthy heart can handle this extra load, a diseased heart can't always cope. "Different kinds of heart diseases may cause different problems during pregnancy," says Croft.

Even normal pregnancies produce cardiac and respiratory symptoms that can mimic more serious complications. "So it's vital to differentiate normal signs and symptoms of pregnancy from a true problem during pregnancy," says Croft.

Symptoms that can arise during a normal pregnancy include fatigue, shortness of breath, swelling in lower extremities, dizziness, lightheadedness, palpitations and increased heart rate.

"Pregnant women should tell their physician if they experience any of these symptoms, so their physician can determine if any evaluation is needed," says Croft.

It's good to keep an eye out for the symptoms of a significant problem. The warning signs for pre-eclampsia include visual disturbances, severe headaches, abdominal pain and lower-extremity swelling. Arrhythmias can cause palpitations, dizziness, fainting, shortness of breath and chest discomfort.

Traditional treatment

Providing medical care for pregnant cardiac patients poses extra challenges. "Some patients may only require reassurance, while some more require in-depth counseling," says Croft. "And if you take medications, it's key that your doctor advises you about which are best for pregnancy."

Good medications are available for treating chronic and gestation hypertension, though the only treatment for pre-eclampsia is delivering the baby.

Only in rare cases do pregnant patients require cardiac surgery.

"Some women may be surgical candidates because they have acute aortic dissection, an acute regurgitant valve or severe valvular stenosis," says Croft. "But a much more common part of my job is reassuring women with low-risk cardiac pathology about their condition, thus eliminating unnecessary anxiety."

Research breakthroughs

Thanks to surgical and medical management advances, many women with congenital heart disease now live to childbearing age and can successfully carry a pregnancy.

"The medical care of a pregnant cardiac patient is a considerable challenge," says Croft. "But with good communication between obstetricians and cardiologists, we can successfully manage care for these patients despite their elevated risk."

Questions for your doctor

A great question for every woman to ask, is "Do I have any restrictions during my pregnancy?" If you have a diagnosed heart problem, ask: "Is my child at risk to inherit my heart condition?"
Another good question is, "Am I at increased risk of C-section?

What you can do

Make sure that your doctor knows about any medications you're taking, including over-the-counter ones. If you have a known heart problem, talk to your physician going through pregnancy.

Watch your blood pressure.

Dr. Lori Croft advises patients to have their blood pressure checked often throughout pregnancy.
Stay healthy.

The rules everyone knows about are indeed essential: Don't drink or smoke, eat healthy and exercise if your doctor allows it.

nydailynews.com

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Treatment for high blood pressure in African-Americans needs to start sooner and be more aggressive, according to a consensus statement by the International Society on Hypertension in Blacks (ISHIB) that is published in Hypertension: Journal of the American Heart Association.

"Evidence from several recently completed studies converged to convince our committee that we were waiting a little bit too long to start treating hypertension in African-Americans," said lead author John M. Flack, MD, of the Department of Internal Medicine at Wayne State University in Detroit, MI, in an online report of the study.

The update to the ISHIB's 2003 consensus statement—for which Flack and colleagues reviewed hypertension and cardiovascular disease prevention and treatment guidelines, pharmacological hypertension clinical end point trials, and blood pressure-lowering trials in African-Americans—includes two major recommendations:

* The thresholds at which treatment is initiated in African-American patients should be lowered.
* Physicians should move quickly from single-drug therapy to multi-drug therapy to keep a patient's blood pressure comfortably below the thresholds

"We believe that these recommendations will lead to better blood pressure control, and a better outlook for African-Americans with high blood pressure," Flack said.

Currently, blood pressure below 120/80 is considered normal for healthy adults. However, the ISHIB is proposing that physicians recommend lifestyle changes to lower blood pressure in otherwise healthy African-Americans with blood pressure at or above 115/75. Those changes include reduced dietary sodium and increased potassium from eating more fruits and vegetables, as well as losing weight, getting regular aerobic exercise, and consuming alcohol in moderation, Flack said.

"Epidemiological data shows that 115/75 is the critical blood pressure number for adults, and every time that figure goes up by 20/10 the risk of cardiovascular disease essentially doubles. We think it makes perfect sense to start lifestyle changes at that lower threshold," he said, pointing out that from age 50 and up, Americans have a 90% chance of developing hypertension.

The ISHIB also recommends that physicians tighten the primary prevention threshold to 135/80 for African-Americans, and begin secondary prevention when blood pressure is at or above 130/80, according to the statement, which provides step-by-step guidance on the best second, third, and fourth drugs to add based on individual patient characteristics, along with charts with alternate multi-drug combinations so physicians have several options for keeping patients' blood pressure under targets.

hcplive.com

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On the first day of basketball practice, Elizabeth Pearlman passed out with a heart condition, but an AED saved her life. “What if it happened somewhere where an AED wasn’t available?” she asked.

Chicago native Elizabeth Pearlman was taking part in a conditioning drill with her college basketball team last October when she collapsed.

If an automated external defibrillator -- an AED is a portable device that can detect cardiac arrhythmias and shock the heart back into rhythm -- hadn't been available, she likely would have died. Pearlman hopes that by sharing her story she might raise awareness -- and ultimately help save others.

"It was the first day of practice," the Aurora University senior said. "At the end of practice, we were doing sprints. On the last sprint, I suddenly felt like I had to stop running. Did I feel faint? No. I just knew that I didn't feel right. The next thing I saw was the floor coming to my face."

Fortunately, Aurora head athletic trainer Terry Smith was at the practice. He saw Pearlman go down. Was she just tired? He doubted that. He sensed something was wrong, and went directly over to her. He saw that she was having a hard time breathing and was hyperventilating. Then he saw her eyes roll back in her head.

"It went downhill real quick," Smith said.

He told one coach to call 911, and told another to get an AED. He immediately began performing CPR. But Pearlman didn't respond to the CPR. Smith had to use the AED to restore her heart rhythm. He had to shock her twice.

"I don't know how much time passed," Smith said. "But time flew. Then the ambulance came."

Pearlman, 21, remembers being in a state of euphoria before regaining full consciousness in the ambulance.

"I was in a great place -- it was deep and solid," she said. "Then I started feeling pricks and pokes, and I woke up to [the paramedics] putting needles in my veins."

Pearlman would spend the next week in the intensive care unit. She would learn that she suffers from a previously undiagnosed genetic heart disease called arrhythmogenic right ventricular dysplasia. She also had suffered a pulmonary embolism. In the months that followed she would undergo several medical procedures, including having an implantable cardioverter defibrillator, or ICD, put in her chest. She has become an expert on her heart condition. She knows she had a close call. Make that a very close call.

"If not for the AED, you're dead," she said. "Growing up, I played basketball in some pretty tough city neighborhoods. I played pick-up games with guys, and we were always running. What if it had happened then? What if it had happened somewhere where an AED wasn't available?"

If it were up to organizations such as the American Red Cross, you would find an AED on every playground and in every home. Because CPR alone isn't always enough. AEDs are not useful for every arrhythmia, but they can detect two that are frequently implicated in sudden cardiac arrest, ventricular fibrillation and ventricular tachycardia.

"If you have an AED, it can increase your chance [of survival]," said Theresa Rees, manager of instruction and development for the Red Cross of Greater Chicago.

Fortunately, you can find AEDs in more places than ever before. They're small, light and easy to use.

"They are in all sporting facilities, government buildings, airports, schools, police cars, ambulances [and other places, as well]," Rees said.

Even those without training should not hesitate to use one in a crisis. But ideally everyone would learn from a professional.

Paramedic Lisa Krch, the CPR training coordinator for Advocate Christ Medical Center's Center for Prehospital Care in southwest suburban Oak Lawn, has taught thousands of people how to use an AED.

"You can teach anyone to use them," Krch said. "I've taught Boy Scouts -- 8-year-old kids. You just follow the prompts. Turn the machine on, then one prompt at a time. It won't go to the next step until you've completed the step you're on."

Advocate Christ has for the past two years gone into high schools to teach CPR, AED and basic first aid.

"Last year alone we taught 1,000 people," Krch said. "I wish they would make it a requirement of high school graduation that you need to know CPR and AED. It's less than eight hours, and it could save a life."

Twelve months ago, Pearlman's life changed drastically. She can no longer play basketball -- her heart condition won't allow it. But she's on target to graduate with her class, and she hopes to attend veterinary school. She's not only alive, she is full of life. Spread the word.

"AEDs are very, very important," she said.

suntimes.com

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Katherine Heigl's plan to kick her cigarette addiction by turning to the electronic version of butts may just go up in smoke.

Heigl, demonstrating for David Letterman last week how she puffs on an e-cigarette, said it has worked for her where nicotine gum, nicotine patches and a prescription drug did not.
"You blow out water vapor so you're not harming anyone around you and you're not harming yourself," she said. "I'm essentially humidifying the space."

"I know it’s ridiculous, but it’s helping me not to actually smoke real cigarettes," Heigl said in an interview with Parade.

But e-cigarettes not only contain nicotine, but whatever chemicals leach out of the plastic tubing that is part of the device, Dr. Len Horovitz, internist and pulmonary specialist at Lenox Hill Hospital told the News.

Electronic cigarettes, which unlike regular cigarettes don't burn tobacco, are smoked with the aid of a battery-operated device. The smoker inhales a vapor that contains nicotine in liquid, which comes in a replaceable cartridge.

"Medically it is exactly like a nicotine addiction," he says. "And inhaling fumes from the plastic tubes can be carcinogenic."

Electronic cigarettes "are not a good way or an approved way to quit smoking," says Dr. Jonathan Whiteson, medical director of the Cardiac and Pulmonary Wellness and Rehabilitation Program at NYU Langone Medical Center.

"They have never been proven to be effective at smoking cessation," he says. "There are many claims, none of which have been substantiated."

Besides the nicotine itself, some of the chemicals in the propellant that helps to vaporize the nicotine are dangerous, too, Whiteson notes.

Electronic cigarettes are not FDA approved, and aren’t currently subject to strict regulation, notes Kathy Garrett Szymanski, respiratory therapist in the thoracic center at Long Island College Hospital, where she directs the smoking cessation program.

"At this point, they are a drug delivery service," she says. "It’s a little cigarette that lets you inhale nicotine. And inhalation is the fastest route of drug delivery. I do not recommend them."

Bottom line? "It’s nicotine, it’s a drug, it’s addictive and it has health consequences," Whiteson says.

With 70% of those who try to kick the habit thwarted in their efforts, smoking remains a tough addiction to beat. But the best way to quit, Horovitz says, is with the nicotine patch and, if necessary, the chewing gum.

"These have been found to be superior to all the pills that are out there," he said. "But there is no magic way to quit smoking anymore than there is a magic way to diet."

Heigl told Letterman that she warn her daughter against the dangers of smoking.

"The one thing I would say to my kid is, "It’s not just that it’s bad for you. Do you want to spend the rest of your life fighting a stupid addiction to a stupid thing that doesn’t even really give you a good buzz?' "

nydailynews.com

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The initial diagnosis of acute coronary syndrome (ACS) is based on history, risk factors, and, to a lesser extent, ECG findings. The symptoms are due to myocardial ischemia, the underlying cause of which is an imbalance between supply and demand of myocardial oxygen.

Patients with ACS include those whose clinical presentations cover the following range of diagnoses: unstable angina, non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). This ACS spectrum concept is a useful framework for developing therapeutic strategies.

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

[ CLOSE WINDOW ]

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

[ CLOSE WINDOW ]

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

Pathophysiology

Myocardial ischemia is most often due to atherosclerotic plaques, which reduce the blood supply to a portion of myocardium. Initially, the plaques allow sufficient blood flow to match myocardial demand. When myocardial demand increases, the areas of narrowing may become clinically significant and precipitate angina. Angina that is reproduced by exercise, eating, and/or stress and is subsequently relieved with rest, and without recent change in frequency or severity of activity that produce symptoms, is called chronic stable angina. Over time, the plaques may thicken and rupture, exposing a thrombogenic surface upon which platelets aggregate and thrombus forms. The patient may note a change in symptoms of cardiac ischemia with a change in severity or of duration of symptoms. This condition is referred to as unstable angina.

Patients with STEMI have a high likelihood of a coronary thrombus occluding the infarct artery. Angiographic evidence of coronary thrombus formation may be seen in more than 90% of patients with STEMI but in only 1% of patients with stable angina and about 35-75% of patients with unstable angina or NSTEMI. However, not every STEMI evolves into a Q-wave MI; likewise, a patient with NSTEMI may develop Q waves.

The excessive mortality rate of coronary heart disease is primarily due to rupture and thrombosis of the atherosclerotic plaque. Inflammation plays a critical role in plaque destabilization and is widespread in the coronary and remote vascular beds. Systemic inflammatory, thrombotic, and hemodynamic factors are relevant to the outcome. Evidence indicates that platelets contribute to promoting plaque inflammation as well as thrombosis. A new theory of unbalanced cytokine-mediated inflammation is emerging, providing an opportunity for intervention.

A less common cause of angina is dynamic obstruction, which may be caused by intense focal spasm of a segment of an epicardial artery (Prinzmetal angina). Coronary vasospasm is a frequent complication in patients with connective tissue disease. Other causes include arterial inflammation and secondary unstable angina. Arterial inflammation may be caused by or related to infection. Secondary unstable angina occurs when the precipitating cause is extrinsic to the coronary arterial bed, such as fever, tachycardia, thyrotoxicosis, hypotension, anemia, or hypoxemia. Most patients who experience secondary unstable angina have chronic stable angina as a baseline medical condition.

Spontaneous and cocaine-related coronary artery dissection remains an unusual cause of ACS and should be included in the differential diagnosis, especially when a younger female or cocaine user is being evaluated. An early clinical suspicion of this disease is necessary for a good outcome. Cardiology consultation should be obtained for consideration for urgent percutaneous coronary intervention.

Although rare, pediatric and adult ACS may result from the following (see Myocardial Infarction in Childhood):

• ACS may occur with Marfan syndrome; Kawasaki disease; Takayasu arteritis; or cystic medial necrosis with aortic root dilatation, aneurysm formation, and dissection into the coronary artery.
• Anomalous origin of the left coronary artery from the pulmonary artery may occur as unexplained sudden death in a neonate.
• Coronary artery ostial stenosis may occur after repair of a transposition of the great arteries in the neonatal period.
• An aberrant left main coronary artery with its origin at the right sinus of Valsalva may cause ACS, especially with exertion.
• Traumatic myocardial infarction can occur in patients at any age.
• Accelerated atherosclerosis is known to occur in cardiac transplant recipients on immunosuppressive therapy.
• ACS may occur with progeria.

Irrespective of the cause of unstable angina, the result of persistent ischemia is myocardial infarction (MI).

Frequency

United States

Although the exact incidence of ACS is difficult to ascertain, hospital discharge data indicate that 1,680,000 unique discharges for ACS occurred in 2001.

International

In Britain, annual incidence rate of angina is estimated at 1.1 cases per 1000 males and 0.5 cases per 1000 females aged 31-70 years. In Sweden, chest pain of ischemic origin is thought to affect 5% of all males aged 50-57 years. In industrialized countries, annual incidence rate of unstable angina is approximately 6 cases per 10,000 people.

Mortality/Morbidity

When the only therapy for angina was nitroglycerin and limitation of activity, patients with newly diagnosed angina had a 40% incidence of MI and a 17% mortality rate within 3 months. A recent study shows that the 30-day mortality rate from ACS has decreased as treatment has improved, a statistically significant 47% relative decrease in 30-day mortality rate among newly diagnosed ACS from 1987-2000. This decrease in mortality rate is attributed to aspirin, glycoprotein (GP) IIb/IIIa blockers, and coronary revascularization via medical intervention or procedures.

Clinical characteristics associated with a poor prognosis include advanced age, male sex, prior MI, diabetes, hypertension, and multiple-vessel or left-mainstem disease.

Sex

Incidence is higher in males among all patients younger than 70 years. This is due to the cardioprotective effect of estrogen in females. At 15 years postmenopause, the incidence of angina occurs with equal frequency in both sexes. Evidence exists that women more often have coronary events without typical symptoms, which might explain the frequent failure to initially diagnose ACS in women.

Age

ACS becomes progressively more common with increasing age. In persons aged 40-70 years, ACS is diagnosed more often in men than in women. In persons older than 70 years, men and women are affected about equally.

Clinical

History

• Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It is usually described as a sensation of chest pressure or heaviness, which is reproduced by activities or conditions that increase myocardial oxygen demand.
• Not all patients experience chest pain. Some present with only neck, jaw, ear, arm, or epigastric discomfort.
• Other symptoms, such as shortness of breath or severe weakness, may represent anginal equivalents.
• A patient may present to the ED because of a change in pattern or severity of symptoms. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).
• Patients may have no pain and may only complain of episodic shortness of breath, weakness, lightheadedness, diaphoresis, or nausea and vomiting.
• Patients may complain of the following:
  • Palpitations
  • Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm
  • Exertional dyspnea that resolves with pain or rest
  • Diaphoresis from sympathetic discharge
  • Nausea from vagal stimulation
  • Decreased exercise tolerance
  • Patients with diabetes and elderly patients are more likely to have atypical presentations and offer only vague complaints, such as weakness, dyspnea, lightheadedness, and nausea.
• Stable angina
  • Involves episodic pain lasting 5-15 minutes
  • Provoked by exertion
  • Relieved by rest or nitroglycerin
• Unstable angina: Patients have increased risk for adverse cardiac events, such as MI or death. Three clinically distinct forms exist, as follows:
  • New-onset exertional angina
  • Angina of increasing frequency or duration or refractory to nitroglycerin
  • Angina at rest
• Variant angina (Prinzmetal angina)
  • Occurs primarily at rest
  • Triggered by smoking
  • Thought to be due to coronary vasospasm
• Elderly persons and those with diabetes may have particularly subtle presentations and may complain of fatigue, syncope, or weakness. Elderly persons may also present with only altered mental status. Those with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.
• As many as half of cases of ACS are clinically silent in that they do not cause the classic symptoms described above and consequently go unrecognized by the patient. Maintain a high index of suspicion for ACS especially when evaluating women, patients with diabetes, older patients, patients with dementia, and those with a history of heart failure.

Physical

• Physical examination results are frequently normal. If chest pain is ongoing, the patient will usually lie quietly in bed and may appear anxious, diaphoretic, and pale.
• Hypertension may precipitate angina or reflect elevated catecholamine levels due to either anxiety or exogenous sympathomimetic stimulation.
• Hypotension indicates ventricular dysfunction due to myocardial ischemia, infarction, or acute valvular dysfunction.
• Jugular venous distention
• Third heart sound (S₃) may be present.
• A new murmur may reflect papillary muscle dysfunction.
• Rales on pulmonary examination may suggest left ventricular (LV) dysfunction or mitral regurgitation.
• Presence of a fourth heart sound (S₄) is a common finding in patients with poor ventricular compliance due to preexisting ischemic heart disease or hypertension.

Causes

• Atherosclerotic plaque is the predominant cause. Coronary artery vasospasm is less common.
• Alternative causes of angina include the following:
  • Ventricular hypertrophy due to hypertension, valvular disease, or cardiomyopathy
  • Embolic occlusion of the coronary arteries
  • Hypoxia, as in carbon monoxide poisoning or acute pulmonary disorders
  • Cocaine and amphetamines, which increase myocardial oxygen demand and may cause coronary vasospasm
  • Underlying coronary artery disease, which may be unmasked by severe anemia
  • Inflammation of epicardial arteries
  • Coronary artery dissection
• Risk factors for ACS should be documented and include the following:
  • Male gender
  • Diabetes mellitus (DM)
  • Smoking history
  • Hypertension
  • Increased age
  • Hypercholesterolemia
  • Hyperlipidemia
  • Prior cerebrovascular accident (CVA) - These patients constitute 7.5% of patients with ACS and have high-risk features.
  • Inherited metabolic disorders
  • Methamphetamine use
  • Occupational stress
  • Connective tissue disease

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The millions of people who take calcium supplements to strengthen aging bones and ward off osteoporosis may be putting themselves at increased risk of a heart attack, a new study has found.

Older people who take at least 500 milligrams of calcium daily—less than the amount in a typical one-a-day calcium pill—are 30% more likely to have a heart attack than those who take no calcium at all, the study estimates.

But people taking calcium supplements should not stop without consulting their doctor, says John Baron, MD, a professor of medicine at Dartmouth Medical School, in Lebanon, N.H., and a co-author of the study. More research is needed to confirm and clarify the results, he says.

The modest benefit that calcium supplements have on building bone density and reducing bone fractures may not justify the heart risks for most patients, Dr. Baron and his colleagues suggest. Bone loss and fractures are a major health concern among older people.

The findings, published in the journal BMJ, have some experts questioning whether calcium supplements should be used as widely as they are now, especially by elderly women, who suffer disproportionately from both heart disease and osteoporosis.

Sharonne Hayes, MD, the director of the Women’s Heart Clinic at the Mayo Clinic, in Rochester, Minn., says that in the past she did not discourage any of her patients from taking calcium supplements. Now, she says, she will try to determine if her patients have a calcium deficiency before making a recommendation either way.

“Up until this point, there was no evidence of harm,” says Dr. Hayes, who was not involved in the new research. “Now there needs to be a good reason to use [supplements].”

In the study, researchers combined data from 11 clinical trials in which patients were randomly assigned to receive calcium supplements or placebo pills. In all, the trials included nearly 12,000 people who were followed for an average of about four years. Most were women, and the average age was 72.

About 2.7% of the participants taking calcium had heart attacks during the trials, compared with 2.2% of those taking a placebo. This translated into an increased risk of between 27% and 31%, depending on how the researchers analyzed the data.

Although the increase in risk associated with calcium supplements was small, it could represent a large number of additional heart attacks in the general population because of how many people take the supplements, the authors note.

Dr. Baron was surprised by the findings. “Calcium supplements have been widely used for quite a while,” he says. “Other studies have suggested, if anything, that [calcium] might have a protective effect.”

The findings do not imply that people should reduce the amount of calcium in their diet, Dr. Hayes stresses. Calcium is found in vegetables, fortified cereal, and dairy products such as milk and yogurt, which are an important source of vitamin D in addition to calcium.

“Calcium isn’t bad,” she says.

John Cleland, MD, a cardiologist at Hull York Medical School, in the U.K., says that calcium supplements are helpful for “very few” patients.

They may be beneficial for some children, some pregnant women, and people with proven calcium deficiency (a relatively rare condition), says Dr. Cleland, who co-authored an editorial accompanying the study. But, he adds, “there’s no evidence for use in older people” who do not have calcium deficiencies.

Doctors should not recommend calcium supplements for patients with osteoporosis unless the patients are also taking an effective osteoporosis treatment, Dr. Cleland and his co-author conclude.

It’s unclear how calcium supplements might increase heart attack risk. They may contribute to the hardening of arteries (atherosclerosis) by increasing calcium levels in the blood, or they may cause changes to blood flow. Hormone responses caused by calcium may also be involved, the study notes.

The study leaves several unanswered questions for future research. The researchers only included patients who were taking calcium supplements but not vitamin D supplements, for instance. That combination—often found in a single pill—is common and may have a different effect than calcium alone on heart risk, as vitamin D is believed to promote heart health.

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Some risk factors for heart disease can be controlled, and some can't. According to the American Heart Association, these are the leading factors that put you at risk for coronary artery disease or a heart attack.

* Age: More than 83% of people who die from coronary heart disease are 65 or older. Older women are more likely to die of heart attacks within a few weeks of the attack than older men.

* Being male: Men have a greater risk of heart attack than women do, and they have attacks earlier in life. Even after menopause, when women's death rate from heart disease increases, it's not as great as men's.

* Family history. Those with parents or close relatives with heart disease are more likely to develop it themselves.

* Race: Heart disease risk is higher among African Americans, Mexican Americans, American Indians, native Hawaiians, and some Asian Americans compared to Caucasians.

* Smoking: Cigarette smoking increases your risk of developing heart disease by two to four times.

* High cholesterol: As blood cholesterol rises, so does risk of coronary heart disease.

* High blood pressure: High blood pressure increases the heart's workload, causing the heart to thicken and become stiffer. It also increases your risk of stroke, heart attack, kidney failure, and congestive heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol levels, or diabetes, the risk of heart attack or stroke increases several times.


* Sedentary lifestyle. Inactivity is a risk factor for coronary heart disease.

* Excess weight: People who have excess body fat—especially if a lot of it is at the waist—are more likely to develop heart disease and stroke even if they have no other risk factors.

* Diabetes: Having diabetes seriously increases your risk of developing cardiovascular disease. About three-quarters of people with diabetes die from some form of heart or blood vessel disease.

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The initial diagnosis of acute coronary syndrome (ACS) is based on history, risk factors, and, to a lesser extent, ECG findings. The symptoms are due to myocardial ischemia, the underlying cause of which is an imbalance between supply and demand of myocardial oxygen.

Patients with ACS include those whose clinical presentations cover the following range of diagnoses: unstable angina, non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). This ACS spectrum concept is a useful framework for developing therapeutic strategies.

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

[ CLOSE WINDOW ]

A 50-year-old man with type 1 diabetes mellitus and hypertension presents after experiencing 1 hour of midsternal chest pain that began after eating a large meal. Pain is now present but is minimal. Aspirin is the single drug that will have the greatest potential impact on subsequent morbidity. In the setting of ongoing symptoms and ECG changes, nitrates titrated to 10% reduction in blood pressure and symptoms, beta-blockers, and heparin are all indicated. If the patient continues to have persistent signs and/or symptoms of ischemia, addition of a glycoprotein IIb/IIIa inhibitor should be considered.

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

[ CLOSE WINDOW ]

A 62-year-old woman with a history of chronic stable angina and a "valve problem" presents with new chest pain. She is symptomatic on arrival, complaining of shortness of breath and precordial chest tightness. Her initial vital signs are blood pressure 140/90 mm Hg and heart rate is 98. Her ECG is as shown. She is given nitroglycerin sublingually, and her pressure decreases to 80/palpation. Right ventricular ischemia should be considered in this patient.

Pathophysiology

Myocardial ischemia is most often due to atherosclerotic plaques, which reduce the blood supply to a portion of myocardium. Initially, the plaques allow sufficient blood flow to match myocardial demand. When myocardial demand increases, the areas of narrowing may become clinically significant and precipitate angina. Angina that is reproduced by exercise, eating, and/or stress and is subsequently relieved with rest, and without recent change in frequency or severity of activity that produce symptoms, is called chronic stable angina. Over time, the plaques may thicken and rupture, exposing a thrombogenic surface upon which platelets aggregate and thrombus forms. The patient may note a change in symptoms of cardiac ischemia with a change in severity or of duration of symptoms. This condition is referred to as unstable angina.

Patients with STEMI have a high likelihood of a coronary thrombus occluding the infarct artery. Angiographic evidence of coronary thrombus formation may be seen in more than 90% of patients with STEMI but in only 1% of patients with stable angina and about 35-75% of patients with unstable angina or NSTEMI. However, not every STEMI evolves into a Q-wave MI; likewise, a patient with NSTEMI may develop Q waves.

The excessive mortality rate of coronary heart disease is primarily due to rupture and thrombosis of the atherosclerotic plaque. Inflammation plays a critical role in plaque destabilization and is widespread in the coronary and remote vascular beds. Systemic inflammatory, thrombotic, and hemodynamic factors are relevant to the outcome. Evidence indicates that platelets contribute to promoting plaque inflammation as well as thrombosis. A new theory of unbalanced cytokine-mediated inflammation is emerging, providing an opportunity for intervention.

A less common cause of angina is dynamic obstruction, which may be caused by intense focal spasm of a segment of an epicardial artery (Prinzmetal angina). Coronary vasospasm is a frequent complication in patients with connective tissue disease. Other causes include arterial inflammation and secondary unstable angina. Arterial inflammation may be caused by or related to infection. Secondary unstable angina occurs when the precipitating cause is extrinsic to the coronary arterial bed, such as fever, tachycardia, thyrotoxicosis, hypotension, anemia, or hypoxemia. Most patients who experience secondary unstable angina have chronic stable angina as a baseline medical condition.

Spontaneous and cocaine-related coronary artery dissection remains an unusual cause of ACS and should be included in the differential diagnosis, especially when a younger female or cocaine user is being evaluated. An early clinical suspicion of this disease is necessary for a good outcome. Cardiology consultation should be obtained for consideration for urgent percutaneous coronary intervention.

Although rare, pediatric and adult ACS may result from the following (see Myocardial Infarction in Childhood):

• ACS may occur with Marfan syndrome; Kawasaki disease; Takayasu arteritis; or cystic medial necrosis with aortic root dilatation, aneurysm formation, and dissection into the coronary artery.
• Anomalous origin of the left coronary artery from the pulmonary artery may occur as unexplained sudden death in a neonate.
• Coronary artery ostial stenosis may occur after repair of a transposition of the great arteries in the neonatal period.
• An aberrant left main coronary artery with its origin at the right sinus of Valsalva may cause ACS, especially with exertion.
• Traumatic myocardial infarction can occur in patients at any age.
• Accelerated atherosclerosis is known to occur in cardiac transplant recipients on immunosuppressive therapy.
• ACS may occur with progeria.

Irrespective of the cause of unstable angina, the result of persistent ischemia is myocardial infarction (MI).

Frequency

United States

Although the exact incidence of ACS is difficult to ascertain, hospital discharge data indicate that 1,680,000 unique discharges for ACS occurred in 2001.

International

In Britain, annual incidence rate of angina is estimated at 1.1 cases per 1000 males and 0.5 cases per 1000 females aged 31-70 years. In Sweden, chest pain of ischemic origin is thought to affect 5% of all males aged 50-57 years. In industrialized countries, annual incidence rate of unstable angina is approximately 6 cases per 10,000 people.

Mortality/Morbidity

When the only therapy for angina was nitroglycerin and limitation of activity, patients with newly diagnosed angina had a 40% incidence of MI and a 17% mortality rate within 3 months. A recent study shows that the 30-day mortality rate from ACS has decreased as treatment has improved, a statistically significant 47% relative decrease in 30-day mortality rate among newly diagnosed ACS from 1987-2000. This decrease in mortality rate is attributed to aspirin, glycoprotein (GP) IIb/IIIa blockers, and coronary revascularization via medical intervention or procedures.

Clinical characteristics associated with a poor prognosis include advanced age, male sex, prior MI, diabetes, hypertension, and multiple-vessel or left-mainstem disease.

Sex

Incidence is higher in males among all patients younger than 70 years. This is due to the cardioprotective effect of estrogen in females. At 15 years postmenopause, the incidence of angina occurs with equal frequency in both sexes. Evidence exists that women more often have coronary events without typical symptoms, which might explain the frequent failure to initially diagnose ACS in women.

Age

ACS becomes progressively more common with increasing age. In persons aged 40-70 years, ACS is diagnosed more often in men than in women. In persons older than 70 years, men and women are affected equally.

Clinical

History

• Typically, angina is a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand. It is usually described as a sensation of chest pressure or heaviness, which is reproduced by activities or conditions that increase myocardial oxygen demand.
• Not all patients experience chest pain. Some present with only neck, jaw, ear, arm, or epigastric discomfort.
• Other symptoms, such as shortness of breath or severe weakness, may represent anginal equivalents.
• A patient may present to the ED because of a change in pattern or severity of symptoms. A new case of angina is more difficult to diagnose because symptoms are often vague and similar to those caused by other conditions (eg, indigestion, anxiety).
• Patients may have no pain and may only complain of episodic shortness of breath, weakness, lightheadedness, diaphoresis, or nausea and vomiting.
• Patients may complain of the following:
  • Palpitations
  • Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm
  • Exertional dyspnea that resolves with pain or rest
  • Diaphoresis from sympathetic discharge
  • Nausea from vagal stimulation
  • Decreased exercise tolerance
  • Patients with diabetes and elderly patients are more likely to have atypical presentations and offer only vague complaints, such as weakness, dyspnea, lightheadedness, and nausea.
• Stable angina
  • Involves episodic pain lasting 5-15 minutes
  • Provoked by exertion
  • Relieved by rest or nitroglycerin
• Unstable angina: Patients have increased risk for adverse cardiac events, such as MI or death. Three clinically distinct forms exist, as follows:
  • New-onset exertional angina
  • Angina of increasing frequency or duration or refractory to nitroglycerin
  • Angina at rest
• Variant angina (Prinzmetal angina)
  • Occurs primarily at rest
  • Triggered by smoking
  • Thought to be due to coronary vasospasm
• Elderly persons and those with diabetes may have particularly subtle presentations and may complain of fatigue, syncope, or weakness. Elderly persons may also present with only altered mental status. Those with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.
• As many as half of cases of ACS are clinically silent in that they do not cause the classic symptoms described above and consequently go unrecognized by the patient. Maintain a high index of suspicion for ACS especially when evaluating women, patients with diabetes, older patients, patients with dementia, and those with a history of heart failure.

Physical

• Physical examination results are frequently normal. If chest pain is ongoing, the patient will usually lie quietly in bed and may appear anxious, diaphoretic, and pale.
• Hypertension may precipitate angina or reflect elevated catecholamine levels due to either anxiety or exogenous sympathomimetic stimulation.
• Hypotension indicates ventricular dysfunction due to myocardial ischemia, infarction, or acute valvular dysfunction.
• Congestive heart failure (CHF)
• Jugular venous distention
• Third heart sound (S₃) may be present.
• A new murmur may reflect papillary muscle dysfunction.
• Rales on pulmonary examination may suggest left ventricular (LV) dysfunction or mitral regurgitation.
• Presence of a fourth heart sound (S₄) is a common finding in patients with poor ventricular compliance due to preexisting ischemic heart disease or hypertension.

Causes

• Atherosclerotic plaque is the predominant cause. Coronary artery vasospasm is less common.
• Alternative causes of angina include the following:
  • Ventricular hypertrophy due to hypertension, valvular disease, or cardiomyopathy
  • Embolic occlusion of the coronary arteries
  • Hypoxia, as in carbon monoxide poisoning or acute pulmonary disorders
  • Cocaine and amphetamines, which increase myocardial oxygen demand and may cause coronary vasospasm
  • Underlying coronary artery disease, which may be unmasked by severe anemia
  • Inflammation of epicardial arteries
  • Coronary artery dissection
• Risk factors for ACS should be documented and include the following:
  • Male gender
  • Diabetes mellitus (DM)
  • Smoking history
  • Hypertension
  • Increased age
  • Hypercholesterolemia
  • Hyperlipidemia
  • Prior cerebrovascular accident (CVA) - These patients constitute 7.5% of patients with ACS and have high-risk features.
  • Inherited metabolic disorders
  • Methamphetamine use
  • Occupational stress
  • Connective tissue disease

• Source: Emedicine.medscape
  

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The most common symptom of coronary artery disease is angina or "angina pectoris," also known simply as chest pain. Angina can be described as a discomfort, heaviness, pressure, aching, burning, fullness, squeezing, or painful feeling due to coronary heart disease. Often, it can be mistaken for indigestion.

Angina is usually felt in the chest, but may also be felt in the shoulders, arms, neck, throat, jaw, or back.

If you have this symptom, take notice. If you've never been diagnosed with heart disease, you should seek treatment immediately. If you've had angina before, use your angina medications as directed by your doctor and try to determine if this is your regular pattern of angina or if the symptoms are worse. (This is called unstable angina, see below.)
What Causes Angina?

Angina is caused when blood flow to an area of the heart is decreased. This impairs the delivery of oxygen and vital nutrients to the heart muscle cells. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body. The byproduct of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes pain. Some medications used to treat angina work by inhibiting the use of this fuel source.
What Are the Types of Angina?
The types of angina are:

* Stable angina. The pain is predictable and present only during exertion or extreme emotional distress, disappearing with rest.
* Unstable angina. This may signal an impending heart attack. Unstable angina is angina pain that is different from your regular angina pain or pain that occurs while at rest. The angina may occur more frequently, more easily at rest, feel more severe, last longer, or come on with minimal activity. Although this type of angina can often be relieved with medication, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure is required.
* Prinzmetal's angina. This is when angina occurs at rest, when sleeping, or when exposed to cold temperatures. In these cases, the symptoms are caused by decreased blood flow to the heart's muscle from a spasm of the coronary artery. The majority of people with this type of angina also have coronary artery disease. These spasms occur close to the blockage.
Can Angina Occur Without Coronary Disease?

Angina can occur in the absence of any coronary disease. Up to 30% of people with angina with a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart. People with severe anemia may have angina because their blood doesn't carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don't get enough.

How Is Angina Evaluated?

To evaluate your angina, your doctor will first ask you a series of questions to determine what your symptoms are and what brings them on. After examining you, your doctor will order one or more of a series of tests to determine the underlying cause of the angina and the extent of coronary artery disease, if present. These tests include:

* Exercise stress test
* Electrocardiogram (ECG or EKG)
* Stress imaging tests, such as nuclear tests or stress echocardiography. These are specialized imaging tests that can accurately localize the part of the heart that has decreased blood flow.
* Echocardiogram
* Cardiac catheterization

How Is Angina Treated?

The angina treatment you receive depends on the severity of the underlying problem, namely the amount of damage to the heart. For most people with mild angina, a combination of drugs and lifestyle changes can control the symptoms. Lifestyle changes include: eating a heart-healthy diet, lowering cholesterol, getting regular exercise, quitting smoking, and controlling diabetes and high blood pressure.

Some drugs used to treat angina work by either increasing the amount of oxygen delivered to the heart muscle or reducing the heart's need for oxygen. These medicines include:

* Beta-blockers
* Nitrates
* Calcium channel blockers
* Ranolazine

Others angina drugs work to prevent the formation of blood clots, which can further block blood flow to the heart muscle. These medicines include:

* Antiplatelet medications

For people with more serious or worsening angina, your doctor may recommend treatment to open blocked arteries. These include:

* Angioplasty
* Stenting
* Coronary artery bypass grafting (CABG) surgery
* External counterpulsation (EECP)

What Should I Do if I Have Angina?

With any type of angina, stop what you are doing and rest.

If you have been prescribed a medication called nitroglycerin to treat your angina, take one tablet and let it dissolve under your tongue. If using the spray form, spray it under your tongue. Wait five minutes.

If you still have angina after five minutes, take another dose of nitroglycerin. Wait another five minutes and if angina is still present, take a third dose.

If you still have angina after resting and taking two doses of nitroglycerin or 15 minutes, call for emergency help (dial 911 in most areas) or have someone take you to the local emergency room.

If you think you are having a heart attack, do not delay. Call for emergency help right away. Do not drive yourself to the hospital. Consider taking an aspirin. Quick treatment of a heart attack is very important to lessen the amount of damage to your heart.
Why Shouldn't I Drive Myself or Have Someone Drive Me to the Hospital?

When the ambulance arrives, the emergency personnel can begin to give you heart-saving care right away. They can start an IV to give you important drugs and give you oxygen to help improve the flow of oxygen-rich blood to your heart. Should problems occur, they are there to provide life-saving help as well.
Something to Remember About Angina

If you have angina, carry nitroglycerin with you at all times; you never know when you will need it. Nitroglycerin must be kept in a dark container. Keep it away from heat or moisture. Check the expiration date on the container. Once the container of nitroglycerin tablets is opened, it must be replaced every three months. The spray form has a longer shelf life and should be replaced every 2 years.

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