|
|
|
Angina
(pronounced an-ji-na) or angina pectoris is produced when the supply of
oxygen that is carried by blood is unable to meet the demands of the heart
muscle. The decreased supply of blood is created by an obstruction within the
coronary artery which impedes blood flow across it. Atherosclerosis is the
commonest cause of obstruction. However, obstruction may also result from
coronary artery spasm or the use of "crack" cocaine. Angina
pectoris is a recurring symptom and usually occurs in the form of chest
discomfort (tightness, fullness, squeezing, heaviness, burning or pain) in
the center of the chest and /or over the left breast). The discomfort may
move to the left shoulder and arm (although it may move to both
shoulders/arms, throat, jaw, or even the lower portion of the chest or upper
abdomen). It may be accompanied by shortness of breath, sweating, weakness,
dizziness or nausea, or numbness in the shoulders, arms and hands. When the
build up of plaque is gradual, the patient's symptoms are relatively
predictable and stable. Such patient's usually have symptoms that are
provoked by specific levels of exercise. They are generally brief, last only
2-3 minutes, and subside promptly with cessation of exercise or following the
use of a nitroglycerin tablet. This pattern of pain is known as stable
angina. The partial and temporary decrease in oxygen supply to the heart
muscle does not generally cause permanent damage (unlike a heart attack).
Some
patients may have atypical (not typical) symptoms. For example, the pain may
be confined to left shoulder, throat, jaw, or between the shoulder blades.
Others may have shortness of breath or sudden weakness, while approximately
10% may have no symptoms, even when the heart is severely stressed or undergoing
a heart attack. Such patients are said to have a defective warning system.
Diabetic patients are more prone to have atypical or no symptoms.
Because
there are several causes of chest pain that are unrelated to the heart, many
patients tend to ignore their symptoms attributing it to heartburn, mitral
valve prolapse, a gall bladder attack, muscle sprain, etc. If you have risk
factors for coronary artery disease and are having unusual symptoms
suggestive of angina or a heart attack, make sure that you consult your
doctor about your complaints.
The
following section will walk you through the various phases of
atherosclerosis. The following "lecture" describes various phases
of the disease. The pictures will change automatically during the audio
presentation. You can play, stop, and rewind the animation/narration by
clicking on the buttons below.
Atherosclerosis
begins with the deposition of fatty streaks on the inner lining of the
artery. Additional deposits lead to a bulky atheroma that begins to encroach
into the channel of the coronary artery. Fibers begin to grow into the
atheroma causing harder plaques. The plaque of atherosclerosis may develop a
crack on its surface. This is known as plaque rupture which can result in the
deposit of a blood clot at the site of the blockage. If the blood clot
totally blocks flow to the heart muscle, a heart attack usually results.
However,
if the clot causes a partial blockage, the patient may develop unstable
angina. Such patients have prolonged, frequent and more severe episodes of
angina. The discomfort may be the patient's first symptom (in which case it
is called new onset angina). In other cases, stable angina gradually or
suddenly changes into a pattern of unstable angina.
The
chest discomfort of unstable angina may become more frequent, last longer, be
more intense, be brought on by lesser degrees of exertion (compared to prior
symptoms), appear at rest or even awaken the patient from a sound sleep. It
is called unstable angina because many untreated patients end up having a
heart attack. Unstable angina may also occur in the absence of a blood clot
if the severity of the blockage (due to the atheroma and plaques) becomes
severe enough to cause a drastic decrease in blood supply to the heart
muscle.
As mentioned
earlier, angina occurs when the coronary artery is unable to supply the
demands of the heart muscle. Thus, it seems logical that the patient's
symptoms would improve only if one was able to increase blood supply or
decrease the oxygen needs of the heart muscle, or achieve a combination of
the two. Listed below are medications commonly used in the treatment of
angina:
Nitroglycerin
and long acting nitrates: Nitroglycerin (NTG) tablets placed under the tongue
(known as sublingual; sub=under and lingua=tongue), is a very effective means
of treating angina. The tablet dissolves under the tongue and may have a
slightly sharp, burning or tingling taste. Tablets which have this taste when
fresh but subsequently become tasteless may indicate loss of effectiveness
and potency. They need to be replaced by a fresh supply when they pass the
expiration date printed on the bottle label; usually a few months after
purchase. NTG is also available in the form of a spray. This spray pump has
the advantage of maintaining its potency for years instead of months.
NTG
placed under the tongue dissolves quickly and demonstrates a beneficial
effect within a minute or two. It works by dilating the coronary artery and
thus improving the supply of blood and oxygen to the heart muscle. NTG also
dilates (opens up) the veins and arteries of the body. Dilated veins decrease
the filling of the left ventricle (LV), which in turn reduces its workload.
On the other hand, dilated arteries of the body reduces the blood pressure and
the resistance that the LV has to overcome in pumping blood through those
arteries. A single NTG tablet should be placed under the tongue if angina
persists beyond a few minutes after stopping activity. If the pain is
unrelieved, a second tablet is used after 5 minutes. This is repeated at 5
minute intervals, if pain persists. It is wise to seek medical attention if
angina is not completely resolved by the fourth tablets. Consecutive tablets
of NTG may cause dizziness if it significantly lowers the blood pressure. In
such cases, the patient should sit or lie down. Persistence of angina after
the use of four NTG tablets at 5 minute intervals should prompt a phone call
to your doctor. Most patients with established or suspected coronary artery
disease will be advised to go to the emergency room or a physician's office,
depending upon the specific case.
NTG tablets placed under the tongue are short acting and lasts only 5 to 10
minutes, which is usually a sufficient amount of time to relieve angina.
However, a different form of NTG is needed for preventing angina from coming
on. They are known as long acting nitrates. Long acting nitrates are
available in the form of pills that are taken one to three times a day
(depending upon the type that is prescribed) , a patch that is applied to the
skin in the morning and removed at night, or an ointment that is placed on
the skin three to four times a day. Patients on long acting nitrates will
need to continue using NTG under the tongue if angina occurs.
Beta
Blockers: The heart
rate and blood pressure are elevated when the body releases increased amounts
of adrenaline under moments of exertion and emotional stress. Adrenaline the
left ventricle contracts more vigorously to provide the body with more blood
flow during the period of activity and stress. The increased blood pressure,
faster heart rate and more forceful pumping of the left ventricle all
increase the need of oxygen by the heart. In patients with coronary artery
disease, angina occurs if the supply of oxygen and blood cannot keep up with
this increased demand
A class of medications known as beta blockers partially "insulates"
the heart and blood vessels from the effects of adrenaline. This lowers the
blood pressure, slows the heart and decreases the force with which the heart
contracts. This in turn reduces the oxygen needs of the heart and thus helps
in preventing the occurrence of angina. There are over a dozen available beta
blockers with similar activities. They have also shown to be benefit in reducing
the risk of a heart attack. Beta blockers are often avoided or used with
great caution in patient's with slow heart beat and obstructive lung disease
(emphysema, bronchitis and asthma). Fatigue, sleepiness, depression and
decreased sexual libido may be experienced by some patients. Some of these
symptoms may improve by changing the dose or type of beta blocker, or with
the passage of time (weeks or months).
Calcium
Channel Blockers: Calcium
channel blockers decrease blood pressure and can dilate coronary arteries.
For these reasons, it is of value in the treatment of patient's with angina;
particularly in patients with high blood pressure or in those who have not
responded to a combination of nitrates and beta blockers.
Aspirin: Aspirin is one of the least
expensive and most valuable medication in the treatment of coronary artery
disease. Platelets are small cells that float around in our blood stream.
They are the "beavers" of the body that rush to seal any break or
breach in the dam. When there is any type of damage or tear in the wall of a
blood vessel, platelets collect in that area, clump together and attract
formation of a clot. This seals the damage and stops bleeding when a person
is injured.
Unfortunately,
the same mechanism comes into play when the coronary artery develops minor
cracks in the inner lining of the coronary artery (plaque rupture). This can
result in a blood clot that seals the artery, cuts off blood supply to the
heart muscle and leads to a heart attack. Aspirin reduces the activity of
platelets, decreases the tendency to form clots and is thus extremely
valuable in lowering the incidence of heart attacks in patients with coronary
artery disease. Aspirin should be avoided in patients with an allergy to the
drug. In such cases, alternative medications may be employed.
Preventive
Measures, risk factor modification, dietary restrictions, smoking cessation
and a structured exercise program are an important cornerstone in the
treatment of coronary artery disease.
|
|
|
Angina
(pronounced an-ji-na) or angina pectoris is produced when the supply of
oxygen that is carried by blood is unable to meet the demands of the heart
muscle. The decreased supply of blood is created by an obstruction within the
coronary artery which impedes blood flow across it. Atherosclerosis is the
commonest cause of obstruction. However, obstruction may also result from
coronary artery spasm or the use of "crack" cocaine. Angina
pectoris is a recurring symptom and usually occurs in the form of chest
discomfort (tightness, fullness, squeezing, heaviness, burning or pain) in
the center of the chest and /or over the left breast). The discomfort may
move to the left shoulder and arm (although it may move to both
shoulders/arms, throat, jaw, or even the lower portion of the chest or upper
abdomen). It may be accompanied by shortness of breath, sweating, weakness,
dizziness or nausea, or numbness in the shoulders, arms and hands. When the
build up of plaque is gradual, the patient's symptoms are relatively
predictable and stable. Such patient's usually have symptoms that are
provoked by specific levels of exercise. They are generally brief, last only
2-3 minutes, and subside promptly with cessation of exercise or following the
use of a nitroglycerin tablet. This pattern of pain is known as stable
angina. The partial and temporary decrease in oxygen supply to the heart
muscle does not generally cause permanent damage (unlike a heart attack).
Some
patients may have atypical (not typical) symptoms. For example, the pain may
be confined to left shoulder, throat, jaw, or between the shoulder blades.
Others may have shortness of breath or sudden weakness, while approximately
10% may have no symptoms, even when the heart is severely stressed or undergoing
a heart attack. Such patients are said to have a defective warning system.
Diabetic patients are more prone to have atypical or no symptoms.
Because
there are several causes of chest pain that are unrelated to the heart, many
patients tend to ignore their symptoms attributing it to heartburn, mitral
valve prolapse, a gall bladder attack, muscle sprain, etc. If you have risk
factors for coronary artery disease and are having unusual symptoms
suggestive of angina or a heart attack, make sure that you consult your
doctor about your complaints.
The
following section will walk you through the various phases of
atherosclerosis. The following "lecture" describes various phases
of the disease. The pictures will change automatically during the audio
presentation. You can play, stop, and rewind the animation/narration by
clicking on the buttons below.
Atherosclerosis
begins with the deposition of fatty streaks on the inner lining of the
artery. Additional deposits lead to a bulky atheroma that begins to encroach
into the channel of the coronary artery. Fibers begin to grow into the
atheroma causing harder plaques. The plaque of atherosclerosis may develop a
crack on its surface. This is known as plaque rupture which can result in the
deposit of a blood clot at the site of the blockage. If the blood clot
totally blocks flow to the heart muscle, a heart attack usually results.
However,
if the clot causes a partial blockage, the patient may develop unstable
angina. Such patients have prolonged, frequent and more severe episodes of
angina. The discomfort may be the patient's first symptom (in which case it
is called new onset angina). In other cases, stable angina gradually or
suddenly changes into a pattern of unstable angina.
The
chest discomfort of unstable angina may become more frequent, last longer, be
more intense, be brought on by lesser degrees of exertion (compared to prior
symptoms), appear at rest or even awaken the patient from a sound sleep. It
is called unstable angina because many untreated patients end up having a
heart attack. Unstable angina may also occur in the absence of a blood clot
if the severity of the blockage (due to the atheroma and plaques) becomes
severe enough to cause a drastic decrease in blood supply to the heart
muscle.
As mentioned
earlier, angina occurs when the coronary artery is unable to supply the
demands of the heart muscle. Thus, it seems logical that the patient's
symptoms would improve only if one was able to increase blood supply or
decrease the oxygen needs of the heart muscle, or achieve a combination of
the two. Listed below are medications commonly used in the treatment of
angina:
Nitroglycerin
and long acting nitrates: Nitroglycerin (NTG) tablets placed under the tongue
(known as sublingual; sub=under and lingua=tongue), is a very effective means
of treating angina. The tablet dissolves under the tongue and may have a
slightly sharp, burning or tingling taste. Tablets which have this taste when
fresh but subsequently become tasteless may indicate loss of effectiveness
and potency. They need to be replaced by a fresh supply when they pass the
expiration date printed on the bottle label; usually a few months after
purchase. NTG is also available in the form of a spray. This spray pump has
the advantage of maintaining its potency for years instead of months.
NTG
placed under the tongue dissolves quickly and demonstrates a beneficial
effect within a minute or two. It works by dilating the coronary artery and
thus improving the supply of blood and oxygen to the heart muscle. NTG also
dilates (opens up) the veins and arteries of the body. Dilated veins decrease
the filling of the left ventricle (LV), which in turn reduces its workload.
On the other hand, dilated arteries of the body reduces the blood pressure and
the resistance that the LV has to overcome in pumping blood through those
arteries. A single NTG tablet should be placed under the tongue if angina
persists beyond a few minutes after stopping activity. If the pain is
unrelieved, a second tablet is used after 5 minutes. This is repeated at 5
minute intervals, if pain persists. It is wise to seek medical attention if
angina is not completely resolved by the fourth tablets. Consecutive tablets
of NTG may cause dizziness if it significantly lowers the blood pressure. In
such cases, the patient should sit or lie down. Persistence of angina after
the use of four NTG tablets at 5 minute intervals should prompt a phone call
to your doctor. Most patients with established or suspected coronary artery
disease will be advised to go to the emergency room or a physician's office,
depending upon the specific case.
NTG tablets placed under the tongue are short acting and lasts only 5 to 10
minutes, which is usually a sufficient amount of time to relieve angina.
However, a different form of NTG is needed for preventing angina from coming
on. They are known as long acting nitrates. Long acting nitrates are
available in the form of pills that are taken one to three times a day
(depending upon the type that is prescribed) , a patch that is applied to the
skin in the morning and removed at night, or an ointment that is placed on
the skin three to four times a day. Patients on long acting nitrates will
need to continue using NTG under the tongue if angina occurs.
Beta
Blockers: The heart
rate and blood pressure are elevated when the body releases increased amounts
of adrenaline under moments of exertion and emotional stress. Adrenaline the
left ventricle contracts more vigorously to provide the body with more blood
flow during the period of activity and stress. The increased blood pressure,
faster heart rate and more forceful pumping of the left ventricle all
increase the need of oxygen by the heart. In patients with coronary artery
disease, angina occurs if the supply of oxygen and blood cannot keep up with
this increased demand
A class of medications known as beta blockers partially "insulates"
the heart and blood vessels from the effects of adrenaline. This lowers the
blood pressure, slows the heart and decreases the force with which the heart
contracts. This in turn reduces the oxygen needs of the heart and thus helps
in preventing the occurrence of angina. There are over a dozen available beta
blockers with similar activities. They have also shown to be benefit in reducing
the risk of a heart attack. Beta blockers are often avoided or used with
great caution in patient's with slow heart beat and obstructive lung disease
(emphysema, bronchitis and asthma). Fatigue, sleepiness, depression and
decreased sexual libido may be experienced by some patients. Some of these
symptoms may improve by changing the dose or type of beta blocker, or with
the passage of time (weeks or months).
Calcium
Channel Blockers: Calcium
channel blockers decrease blood pressure and can dilate coronary arteries.
For these reasons, it is of value in the treatment of patient's with angina;
particularly in patients with high blood pressure or in those who have not
responded to a combination of nitrates and beta blockers.
Aspirin: Aspirin is one of the least
expensive and most valuable medication in the treatment of coronary artery
disease. Platelets are small cells that float around in our blood stream.
They are the "beavers" of the body that rush to seal any break or
breach in the dam. When there is any type of damage or tear in the wall of a
blood vessel, platelets collect in that area, clump together and attract
formation of a clot. This seals the damage and stops bleeding when a person
is injured.
Unfortunately,
the same mechanism comes into play when the coronary artery develops minor
cracks in the inner lining of the coronary artery (plaque rupture). This can
result in a blood clot that seals the artery, cuts off blood supply to the
heart muscle and leads to a heart attack. Aspirin reduces the activity of
platelets, decreases the tendency to form clots and is thus extremely
valuable in lowering the incidence of heart attacks in patients with coronary
artery disease. Aspirin should be avoided in patients with an allergy to the
drug. In such cases, alternative medications may be employed.
Preventive
Measures, risk factor modification, dietary restrictions, smoking cessation
and a structured exercise program are an important cornerstone in the
treatment of coronary artery disease.
|
|
|
Angina
(pronounced an-ji-na) or angina pectoris is produced when the supply of
oxygen that is carried by blood is unable to meet the demands of the heart
muscle. The decreased supply of blood is created by an obstruction within the
coronary artery which impedes blood flow across it. Atherosclerosis is the
commonest cause of obstruction. However, obstruction may also result from
coronary artery spasm or the use of "crack" cocaine. Angina
pectoris is a recurring symptom and usually occurs in the form of chest
discomfort (tightness, fullness, squeezing, heaviness, burning or pain) in
the center of the chest and /or over the left breast). The discomfort may
move to the left shoulder and arm (although it may move to both
shoulders/arms, throat, jaw, or even the lower portion of the chest or upper
abdomen). It may be accompanied by shortness of breath, sweating, weakness,
dizziness or nausea, or numbness in the shoulders, arms and hands. When the
build up of plaque is gradual, the patient's symptoms are relatively
predictable and stable. Such patient's usually have symptoms that are
provoked by specific levels of exercise. They are generally brief, last only
2-3 minutes, and subside promptly with cessation of exercise or following the
use of a nitroglycerin tablet. This pattern of pain is known as stable
angina. The partial and temporary decrease in oxygen supply to the heart
muscle does not generally cause permanent damage (unlike a heart attack).
Some
patients may have atypical (not typical) symptoms. For example, the pain may
be confined to left shoulder, throat, jaw, or between the shoulder blades.
Others may have shortness of breath or sudden weakness, while approximately
10% may have no symptoms, even when the heart is severely stressed or undergoing
a heart attack. Such patients are said to have a defective warning system.
Diabetic patients are more prone to have atypical or no symptoms.
Because
there are several causes of chest pain that are unrelated to the heart, many
patients tend to ignore their symptoms attributing it to heartburn, mitral
valve prolapse, a gall bladder attack, muscle sprain, etc. If you have risk
factors for coronary artery disease and are having unusual symptoms
suggestive of angina or a heart attack, make sure that you consult your
doctor about your complaints.
The
following section will walk you through the various phases of
atherosclerosis. The following "lecture" describes various phases
of the disease. The pictures will change automatically during the audio
presentation. You can play, stop, and rewind the animation/narration by
clicking on the buttons below.
Atherosclerosis
begins with the deposition of fatty streaks on the inner lining of the
artery. Additional deposits lead to a bulky atheroma that begins to encroach
into the channel of the coronary artery. Fibers begin to grow into the
atheroma causing harder plaques. The plaque of atherosclerosis may develop a
crack on its surface. This is known as plaque rupture which can result in the
deposit of a blood clot at the site of the blockage. If the blood clot
totally blocks flow to the heart muscle, a heart attack usually results.
However,
if the clot causes a partial blockage, the patient may develop unstable
angina. Such patients have prolonged, frequent and more severe episodes of
angina. The discomfort may be the patient's first symptom (in which case it
is called new onset angina). In other cases, stable angina gradually or
suddenly changes into a pattern of unstable angina.
The
chest discomfort of unstable angina may become more frequent, last longer, be
more intense, be brought on by lesser degrees of exertion (compared to prior
symptoms), appear at rest or even awaken the patient from a sound sleep. It
is called unstable angina because many untreated patients end up having a
heart attack. Unstable angina may also occur in the absence of a blood clot
if the severity of the blockage (due to the atheroma and plaques) becomes
severe enough to cause a drastic decrease in blood supply to the heart
muscle.
As mentioned
earlier, angina occurs when the coronary artery is unable to supply the
demands of the heart muscle. Thus, it seems logical that the patient's
symptoms would improve only if one was able to increase blood supply or
decrease the oxygen needs of the heart muscle, or achieve a combination of
the two. Listed below are medications commonly used in the treatment of
angina:
Nitroglycerin
and long acting nitrates: Nitroglycerin (NTG) tablets placed under the tongue
(known as sublingual; sub=under and lingua=tongue), is a very effective means
of treating angina. The tablet dissolves under the tongue and may have a
slightly sharp, burning or tingling taste. Tablets which have this taste when
fresh but subsequently become tasteless may indicate loss of effectiveness
and potency. They need to be replaced by a fresh supply when they pass the
expiration date printed on the bottle label; usually a few months after
purchase. NTG is also available in the form of a spray. This spray pump has
the advantage of maintaining its potency for years instead of months.
NTG
placed under the tongue dissolves quickly and demonstrates a beneficial
effect within a minute or two. It works by dilating the coronary artery and
thus improving the supply of blood and oxygen to the heart muscle. NTG also
dilates (opens up) the veins and arteries of the body. Dilated veins decrease
the filling of the left ventricle (LV), which in turn reduces its workload.
On the other hand, dilated arteries of the body reduces the blood pressure and
the resistance that the LV has to overcome in pumping blood through those
arteries. A single NTG tablet should be placed under the tongue if angina
persists beyond a few minutes after stopping activity. If the pain is
unrelieved, a second tablet is used after 5 minutes. This is repeated at 5
minute intervals, if pain persists. It is wise to seek medical attention if
angina is not completely resolved by the fourth tablets. Consecutive tablets
of NTG may cause dizziness if it significantly lowers the blood pressure. In
such cases, the patient should sit or lie down. Persistence of angina after
the use of four NTG tablets at 5 minute intervals should prompt a phone call
to your doctor. Most patients with established or suspected coronary artery
disease will be advised to go to the emergency room or a physician's office,
depending upon the specific case.
NTG tablets placed under the tongue are short acting and lasts only 5 to 10
minutes, which is usually a sufficient amount of time to relieve angina.
However, a different form of NTG is needed for preventing angina from coming
on. They are known as long acting nitrates. Long acting nitrates are
available in the form of pills that are taken one to three times a day
(depending upon the type that is prescribed) , a patch that is applied to the
skin in the morning and removed at night, or an ointment that is placed on
the skin three to four times a day. Patients on long acting nitrates will
need to continue using NTG under the tongue if angina occurs.
Beta
Blockers: The heart
rate and blood pressure are elevated when the body releases increased amounts
of adrenaline under moments of exertion and emotional stress. Adrenaline the
left ventricle contracts more vigorously to provide the body with more blood
flow during the period of activity and stress. The increased blood pressure,
faster heart rate and more forceful pumping of the left ventricle all
increase the need of oxygen by the heart. In patients with coronary artery
disease, angina occurs if the supply of oxygen and blood cannot keep up with
this increased demand
A class of medications known as beta blockers partially "insulates"
the heart and blood vessels from the effects of adrenaline. This lowers the
blood pressure, slows the heart and decreases the force with which the heart
contracts. This in turn reduces the oxygen needs of the heart and thus helps
in preventing the occurrence of angina. There are over a dozen available beta
blockers with similar activities. They have also shown to be benefit in reducing
the risk of a heart attack. Beta blockers are often avoided or used with
great caution in patient's with slow heart beat and obstructive lung disease
(emphysema, bronchitis and asthma). Fatigue, sleepiness, depression and
decreased sexual libido may be experienced by some patients. Some of these
symptoms may improve by changing the dose or type of beta blocker, or with
the passage of time (weeks or months).
Calcium
Channel Blockers: Calcium
channel blockers decrease blood pressure and can dilate coronary arteries.
For these reasons, it is of value in the treatment of patient's with angina;
particularly in patients with high blood pressure or in those who have not
responded to a combination of nitrates and beta blockers.
Aspirin: Aspirin is one of the least
expensive and most valuable medication in the treatment of coronary artery
disease. Platelets are small cells that float around in our blood stream.
They are the "beavers" of the body that rush to seal any break or
breach in the dam. When there is any type of damage or tear in the wall of a
blood vessel, platelets collect in that area, clump together and attract
formation of a clot. This seals the damage and stops bleeding when a person
is injured.
Unfortunately,
the same mechanism comes into play when the coronary artery develops minor
cracks in the inner lining of the coronary artery (plaque rupture). This can
result in a blood clot that seals the artery, cuts off blood supply to the
heart muscle and leads to a heart attack. Aspirin reduces the activity of
platelets, decreases the tendency to form clots and is thus extremely
valuable in lowering the incidence of heart attacks in patients with coronary
artery disease. Aspirin should be avoided in patients with an allergy to the
drug. In such cases, alternative medications may be employed.
Preventive
Measures, risk factor modification, dietary restrictions, smoking cessation
and a structured exercise program are an important cornerstone in the
treatment of coronary artery disease.
|
No comments:
Post a Comment