Once the patient has been diagnosed with acute coronary syndrome (unstable angina or acute myocardial infarction), then they should remain in hospital and rest. If the infarction is due to the total blockage of a coronary artery, then treatment aims to unblock the artery as quickly as possible since every minute counts.

Medicines used during the acute phase are:

Aspirin

Acetylsalicylic acid (aspirin): stops the platelets from aggregating and sticking together inside the artery and therefore reduces the chance of thrombus formation (stationary blood clots). It is the first drug that should be administered at the very onset of chest pain, even while at home.

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Other platelet aggregation inhibitors: these reinforce the action of acetylsalicylic acid as they also prevent platelet aggregation. The most common one is clopidogrel, but prasugrel and ticagrelor are also used in particularly severe cases.

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Anticoagulants: by means of a different mechanism, these also aim to dissolve any thrombi (clots) inside the artery. Different types of heparin are used and may be administered by either intravenous or subcutaneous injections.

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Beta-blockers: they work by slowing down the patient’s heart rate so it is in a more restful state and demands less oxygen. They also reduce the risk of arrhythmias.

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Pain relieving medicines: in several cases patients may require morphine if the pain is very intense.

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Nitroglycerine: can be administered as a tablet, sprayed underneath the tongue or by intravenous injections. It is used to dilate the heart’s arteries allowing more blood to flow through them.

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Thrombolytic or fibrinolytic agents. In cases where a thrombus is completely blocking an artery, these drugs can be administered in order to break the clot down and thin the blood. They are very powerful and only indicated in very specific cases; they are not administered very often, unlike other medicines used for ischaemic cardiomyopathy.

In certain cases the best option is to use drugs to control any ischaemic attacks. In other cases, when dealing with a more severe problem or if medication is insufficient, it is better to try and unblock the artery.

Stent, Angioplasty, percutaneous revascularization

Angioplasty or percutaneous coronary revascularisation. The first step is to take a coronary angiogram, or perform a coronary catheterisation. If an artery is suspected of being totally blocked, then the catheterisation must be performed urgently and without hesitation. The patient should be transferred in a medically equipped ambulance to the nearest health centre capable of realising a coronary angiogram. In cases of angina or infarction without total occlusion of an artery, the coronary angiogram can be deferred for up to 24 hours.

Coronary angiography will reveal which artery or arteries are affected. Using the catheter that has already been introduced at the patient’s groin or wrist, the doctor guides a small balloon to the site of the obstruction and then inflates it with air. And so the procedure helps the artery remain open. Additionally, in the majority of cases, a stent (a spring-like metal tube) is inserted to reinforce the lining of the artery and prevent it from closing again. This procedure is called an angioplasty with stenting.

While stents are almost always metal, they are categorised into two types, drug-eluting or covered and bare metal or uncovered, in function of whether or not they are coated with a drug.

Heart with a bypass

Coronary revascularisation or heart bypass surgery. Sometimes more than one coronary artery is blocked or there are multiple lesions which are difficult to treat with an angioplasty. An alternative solution for such cases is to perform heart bypass surgery. 
It is performed in an operating theatre under general anaesthetic. The surgeon will open the sternum to allow good access to the heart.

The blood stream is sent to a heart-lung machine; this acts as an artificial heart and maintains the blood supply to all of the body’s organs while the heart is treated.

Surgery consists in sowing one of the patient’s own veins or arteries into a position parallel with the diseased vessel, without touching the obstructed section. This creates a bypass, or a secondary circulation, through which the blood can reach the heart muscle without any obstructions. Surgeons use one of the patient’s own arteries, called the internal mammary artery, or a vein taken from the legs.

The essential objective of long-term treatment is secondary prevention, i.e., to ensure there is no recurrence of the angina or infarction (heart attack). This requires a combination of lifestyle changes and drug therapy.

Lifestyle modification

Lifestyle modification is the key to avoiding or preventing Ischaemic Heart Disease as it is much more effective than any pharmaceutical or surgical treatments and does not have any contraindications. Unfortunately, despite this, it sometimes proves to be the most difficult point to achieve. 

do not smoke

Stop smoking. Although it is sometimes difficult, making every effort to quit is always worthwhile

apple

Eat a balanced diet. Patients must take into account both the amount and type of food they eat. Firstly, you should maintain a suitable weight according to your age and height. Secondly, it is important to follow a diet rich in fruits, vegetables, pulses and fish. Regarding meats, you should preferably eat chicken, turkey and rabbit as they have a lower fat content. Finally, only occasionally eat red meats (beef, duck, lamb), cured meats, confectionery and pastries.

take part in regular physical exercise

Exercise regularly. Physical exercise improves cardiac muscle tone and function. It also reduces the likelihood of one of the body’s arteries becoming blocked, besides creating a feeling of physical and emotional well-being. Exercise helps control other risk factors, such as obesity, high blood pressure or diabetes. You do not need to perform intense physical exercise, but it should be done on a regular basis. Choose an activity that you like, e.g., walking, swimming or cycling, and complete vigorous sessions for 30 minutes, 5 times a week. 

Yoga position

Relax. Stressful situations, often related to work or family problems, have a negative impact on our health. The fact that you have suffered a heart attack can also produce a great deal of anxiety and depression. It is important you learn to relax and dedicate a part of each day to looking after yourself. If you find it difficult, then seek help from a professional.

Glucose test

Control the risk factors. Maintaining the diseases associated with atherosclerosis, such as being overweight, diabetes, high blood pressure or high cholesterol levels, under good control helps improve your prognosis.

alcohol

Moderate alcohol consumption. Recommendations are two glasses of wine per day for men and one glass per day for women. The consumption of distilled drinks can have negative repercussions on your cardiovascular health. 

Some medical centres offer cardiac rehabilitation programmes for patients with Ischaemic Heart Disease or cardiac insufficiency (a weak heart). These programmes are based on regular physical exercise performed under supervision, together with diet and lifestyle recommendations adapted to each individual. They have proven very useful in terms of improving patient evolution and are recommended in the vast majority of cases.

Patients with Ischaemic Heart Disease must take a combination of drugs to reduce the heart’s oxygen consumption, dilate the coronary arteries and prevent the formation of a new blockage. 

Green and white pills

Nitroglycerine and its derivatives (nitrates, either as tablets or transdermal patches): these drugs are known as vasodilators. They relax the arteries and veins, including the coronary vessels, thereby increasing blood flow in the affected area and eliminating chest pain from angina. They are also available as ‘quick relief’ tablets; patients with Ischaemic Heart Disease should carry 1 or 2 tablets in their pocket. Whenever the chest pain appears you should stop any physical activities, sit down and place a tablet under your tongue. If the pain subsides in 10 minutes you can restart the activity, but remember to tell your doctor about the episode at your next appointment. By contrast, if the pain does not disappear you should take a second tablet. And if after this the pain persists, then you must call the emergency medical services.

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Beta-blockers (bisoprolol, carvedilol, nebivolol, metoprolol, atenolol, etc.): decrease blood pressure and heart rate, hence the heart requires less oxygen to function correctly. They can also reduce the risk of arrhythmias. Studies have shown that beta-blockers can increase the life expectancy of patients who have had an infarction.

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Platelet aggregation inhibitors. Patients who have suffered any event brought on by atherosclerosis must take platelet aggregation inhibitors permanently, unless they are contraindicated. These drugs stop platelets from clumping together which has the effect of thinning the blood and reduces the risk of thrombus formation inside a coronary artery. Acetylsalicylic acid (aspirin) is the most common platelet inhibitor.

Green and blue pill

Statins. These drugs reduce blood cholesterol levels. They also help stabilise and prevent the rupture of atheromatous plaques, reduce blood vessel inflammation and decrease the likelihood of an infarction. Statins are therefore indicated in all patients with ischaemic cardiomyopathy, even if they have acceptable cholesterol levels.

Blue pills

Other anti-anginal agents are calcium channel blockers, relax the muscles of the coronary arteries and mitigate the effects of obstructions and spasms; ivabradine reduces heart rate and so the heart requires less oxygen and ranolazine acts on the primary and secondary blood vessels and decreases the risk of angina. This latter it is particularly effective in diabetic patients.

Substantiated information by:
Marta FarreroCardiologist — Cardiology DepartmentManel SabatéCardiologist — Cardiology Department

Published: 20 February 2018
Updated: 20 February 2018

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