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Angor

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Coronair vaatleiden

= vernauwing van coronairen
 
- atherosclerose: loskomen van een plaque, thrombose
- spasmen: geinduceerd (amfetamines of cocaine) of niet geinduceerd (Prins Metal Angina)
- arteritis: lupus, ziekte van Takayasu, Ziekte van Kawasaki, rheumatoide arthritis
- structureel: bestralingsfibrose, aneurysma, vaatverwijdingen (ectasieën)
 

Hypoxie thv hart

- anemie (Hb < 8 gr/dl)
- hypotensie voor verlengde duur
- CO intoxicatie
- Thyroid storm
- gasemboli in de coronairen
 

 Risicofactoren

- hypercholesterolaemie
- diabetes mellitus
- hypertensie
- roken
- familiale belasting (eerste graad, AMI < 55 jaar)
- Man > 55 jaar
- vrouw postmenopauzaal
 
 

Thoraxpijn

- dit is het meest frequente symptoom
- ervaren als substernale druk
- zwaartegevoel
- beklemmend
- branden gevoel
- uitstraling naar de armen, schouders, rug, nek en/of kaak
- typische houding: vuist op de borstkas
 

Geassocieerde ss

- dyspnee
- syncope
- vermoeidheid
- zweten
- nausea, braken
- soms bij L.O.: S3 of S4, hoge bloeddruk, mitralisinsufficientie, zwakke perifere pols
 

Equivalenten zonder thoraxpijn

- buikpijn
- syncope
- zweten
- nausea, ev braken
- zwakte
 

Uitlokkende factoren

- eten
- koude
- stress
- inspanning
 

Duur ss

- indien 30 minuten of meer, denk dan aan AMI of niet-cardiale oorzaak
 

Beïnvloedende factoren

- geen invloed van ademhaling of houding
- soms beter met rust en nitroglycerine
 

Wanneer instabiel?

- optreden van nieuwe symptomen
- ook aanwezigheid van symptomen bij rust
- verandering in een gekend patroon van angor
 
 

Anamnese

- is angor stabiel?; dwz enkel bij inspanning of koude en spontaan verdwijnend > 30min
- is angor instabiel?
 
ECG
- in 50% normaal tracé
- steeds vergelijken met vroegere ECG's
- ST segment veranderingen: suggestief voor instabiele angor, 1mm onder de basislijn ter hoogte van 80 msec van het J-punt
- Diferentiaaldiagnose met andere oorzaken:
- pericarditis: eerst diffuse ST-elevaties, gevolgd door T-inversies en PR-depressie
- longembolen: overklaarbare tachycardie, patroon S1, Q3, T3
 

Lab

- hartenzymes zijn niet gestegen
 

RX thorax

- meestal normaal
- soms cardiomegalie (congestief hartfalen, suggestief voor instabiele angor)
- pneumonie
 
Stress testen
= lichamelijke stress-test (vb fietsproef)
= standaard voor definitieve diagnosestelling (stabiel of instabiel)
 
- prognostische factoren
- cardiale ischaemie: ST-daling in 3 opeenvolgende hartslagen, 1 mm onder basislijn, 80 msec na J-punt en minstens 2 nabije afleidingen
- snelle reactie: binnen de 3 minuten is eerder onstabiel, geeft slechtere prognose
- trage reactie: na meer dan 6 minuten geeft een goede prognose
- metingen:
- met alleen ECG: sensitiviteit 68%, specificiteit 77%
- met ECG en echocardio: sensitiviteit 85%, specificiteit 77%
- met nucleaire scan (Thallium-201, Technetium Tc-99m): sensit. 87%, specif. 64%
 

4. DD

- cardiovasculair
- angina pectoris
- AMI
- pericarditis
- mitralisklep prolaps
- aortadissectie
- longen
- pneumothorax
- longembolen
- gastro intestinaal
- oesofagaal (spasme, ruptuur, oesofagitis, reflux)
- maagulcera
- angststoornis
 
 
Eerste opvang
- ABC, IV lijn, O2
- Monitoring, ECG ter plaatse
- Aspirine 160 - 500 mg (contra-indicatie = allergie)
- Nitroglycerine SL (1 spray = 0,4 mg)
- contra-indicaties:
- BDS < 90-100 mm Hg
- op ECG tekenen van rechterventrikel AMI
- Viagra-inname
- indien geen verbetering na 3 doses: waarschijnlijk echt AMI of niet cardiaal
- Morfine: (1 amp = 10 mg)
- posologie: IV 2 mg, evtl te herhalen, SC 2-10 mg
- contra-indicaties: BD < 90 mm Hg, reeds AH-depressie
 

Spoeddienst

- anti-anginosa
- indicaties: angina pectoris, linkerhartfalen (vb longoedeem), hypertensieve crisis
- contra-indicaties: hypotensie, shock, rechterventrikel infarct, Viagra-inname
- welke producten?
- Nitraten SL
- Nitrolingual : 1 dosis spray = 0,4 mg
- Cedocard: 1co = 5, 10, 20 of 40 mg, meestal echter 5 mg
- opm: indien niet beter na 3X dosis: denk aan AMI, onstabiele angor of niet cardiale oorzaak
- Nitraten IV
- Cedocard: 1 amp = 10 mg/10 ml
- Molsidomine
- Corvaton: 1 amp = 20 mg/10ml
- zo nodig aanpassen thuismedicatie:
- B-blokker starten of dosage veranderen.
- Contra-indicaties: hypotensie, Bradyarrhytmie, obstructief longlijden
-Bij  instabiele angor: thrombolytica IV
- altijd eerst Heparine en Aspirine
- combineren met thrombolytica.  Welke producten?
- Tirofiban (Aggrastat)
- eerste 30 min 0,4mg/kg/min
- dan 48 tot 108 uur 0,1 microgram/kg/min
- vormen: flacon van 12,5mg/50ml of prefabinfuus van 12,5mg/250 ml
- Abciximab (Reopro)
- Bolus van 0,25mg/kg

- 1 amp = 10 mg

 

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