What is the difference in treatment between angina and heart attack?

Difference in Treatment Between Angina and Heart Attack

Angina requires chronic preventive therapy with aspirin, beta-blockers, and statins to prevent progression to heart attack, while heart attack demands immediate emergency reperfusion therapy (thrombolysis or primary angioplasty) plus intensive antiplatelet therapy to salvage dying myocardium. 1

Emergency Management: The Critical Distinction

Heart Attack (Acute Myocardial Infarction)

• Immediate ambulance transport is mandatory - the general practitioner should call emergency services and stay with the patient until arrival 1
• Time is muscle: Pre-hospital thrombolysis reduces mortality by 17%, saving 23 lives per 1000 patients per hour of delay 1
• Aspirin 75-325 mg (chewable or water-soluble) must be given immediately upon suspicion of heart attack 1
• Opiates should be administered to relieve pain and anxiety during the acute event 1
• Short-acting nitrates may be given if no bradycardia or hypotension present 1
• Primary coronary angioplasty produces more favorable outcomes than thrombolytics when available within appropriate timeframes 1

Angina (Stable or Unstable)

• Telephone triage is appropriate for less severe chest pain episodes that are distressing but not immediately life-threatening 1
• Sublingual nitroglycerin 0.4 mg provides immediate symptomatic relief, with up to 3 doses at 5-minute intervals 2
• Outpatient management is feasible for stable angina in approximately 70% of cases 1

Long-Term Medical Therapy: Fundamentally Different Goals

Angina Treatment (Preventing Events + Symptom Control)

Antiplatelet Therapy:

• Aspirin 75-150 mg daily is mandatory for all patients with chronic stable angina to prevent MI and death 1, 2, 3
• Clopidogrel 75 mg daily serves only as an alternative if aspirin is contraindicated 1, 2

Beta-Blockers (First-Line):

• Beta-blockers are the cornerstone of chronic stable angina treatment, reducing both symptoms and mortality 1, 2, 3
• Target doses: metoprolol 50-100 mg twice daily, atenolol 50-100 mg daily, or bisoprolol 10 mg once daily 2, 3
• Optimize beta-blocker dose before adding additional antianginal agents 2
• Critical exception: Beta-blockers are absolutely contraindicated in vasospastic angina as they cause unopposed alpha-mediated vasoconstriction 3

Calcium Channel Blockers:

• Equally effective as first-line therapy, particularly when beta-blockers are contraindicated 1, 3
• For vasospastic angina, calcium channel blockers are the gold standard first-line therapy: verapamil 240-480 mg/day, diltiazem 180-360 mg/day, or nifedipine 60-120 mg/day 3

Statins for Risk Reduction:

• High-intensity statin therapy is essential: atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 2
• Target LDL cholesterol <70 mg/dL in established coronary disease 2

ACE Inhibitors:

• Provide vascular protection beyond blood pressure control, particularly in diabetic patients 2, 3
• Ramipril 10 mg daily or perindopril 8 mg daily are evidence-based choices 2

Heart Attack Treatment (Acute + Secondary Prevention)

Acute Phase (First 24-48 Hours):

• Dual antiplatelet therapy is mandatory: aspirin plus clopidogrel (unless urgent CABG planned) 1
• Glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide) are indicated in high-risk patients undergoing percutaneous coronary intervention 1
• Low-molecular-weight heparin (enoxaparin) or unfractionated heparin for anticoagulation 1
• Beta-blockers, nitrates, and morphine for symptom control and hemodynamic stabilization 1

Risk Stratification Period (6-12 Hours):

• Troponin measurements at presentation and 6-12 hours later distinguish NSTEMI from unstable angina 1
• Patients with elevated troponins, recurrent ischemia, ST-segment depression, or hemodynamic instability require early invasive strategy with coronary angiography 1

Post-MI Secondary Prevention:

• Same long-term medications as angina (aspirin, beta-blockers, statins, ACE inhibitors) but with more aggressive targets and mandatory compliance 1
• Implantable cardioverter-defibrillator recommended if LVEF <35% with symptomatic heart failure 1

Revascularization Strategy: Timing is Everything

Angina

• Elective revascularization (PCI or CABG) is indicated when symptoms are not satisfactorily controlled by medical therapy 2, 3
• CABG may reduce mortality in specific subgroups: left main stenosis, proximal LAD stenosis, or three-vessel disease with impaired LV function 3

Heart Attack

• Emergency revascularization within hours - primary PCI is preferred over thrombolysis when available 1
• High-risk unstable angina/NSTEMI requires coronary angiography as soon as possible (within 24-72 hours depending on risk) 1
• Patients with severe ongoing ischemia, major arrhythmias, or hemodynamic instability need angiography within the first hour 1

Critical Pitfalls to Avoid

• Never use beta-blockers in vasospastic (Prinzmetal's) angina - they worsen coronary spasm through unopposed alpha-receptor stimulation 3
• Do not delay ambulance transport for a heart attack patient - the first hour carries the greatest risk for ventricular fibrillation 1
• Do not use dipyridamole as an antiplatelet agent in stable angina - it can enhance exercise-induced myocardial ischemia 1, 2
• Do not withhold beta-blockers in diabetic patients with angina - diabetes is not a contraindication and these patients benefit significantly 1, 2
• Glycoprotein IIb/IIIa inhibitors are not indicated in low-risk patients who do not undergo PCI 1