Ischemic heart disease
Dr. Sumaia Zaki Hamdan Abuelbasher
MBBS UN university
MD internal medicine SMSB
MRCP.UK
M.Sc Clinical pharmacology
Problem
• A 56-year-old man comes to the emergency
room complaining of chest discomfort.
• He describes the discomfort as a severe,
retrosternal pressure sensation that had
awakened him from sleep 3 hours earlier.
• He previously had been well but has a medical
history of hypercholesterolemia and a 40-
pack-per-year history of smoking.
On examination
• He appears uncomfortable and diaphoretic, with a heart
rate of 116 bpm, blood pressure 166/102 mm Hg,
respiratory rate 22 breaths per minute, and oxygen
saturation of 96% on room air.
• Jugular venous pressure appears normal.
• Auscultation of the chest reveals clear lung fields, a
regular rhythm with an S4 gallop, and no murmurs or
rubs.
• A chest radiograph shows clear lungs and a normal cardiac
silhouette.
• The ECG is shown
Questions
1. What is the most likely diagnosis?
2. What other investigations you will requested?
3. What is the immediate therapy?
4. What is curative treatment?
5. What is the complication he developed
already in presentation?
6. What are the other possible complications ?
7. What is long term treatment?
Objectives
1. Definition of ischemic heart disease.
2. Classification of ischemic heart disease.
3. Pathophysiology.
4. Causes.
5. Clinical presentation.
6. Investigations.
7. Management.
Definition
• Ischemia:
• Refers to an insufficient amount of blood.
• The coronary arteries are the only source of
blood for the heart muscle.
• If this coronary arteries are blocked, the blood
supply will reduce.
Pathophysiology
Classification of ischemic heart disease
Acute coronary
Stable angina
syndrome (ACS)
Unstable Decubitus
angina angina
Variant
Myocardium
(Prinzmetal’s)
infarction
angina
Risk factors
Non-modifiable
Modifiable
Non-modifiable
1. Age.
2. Gender.
3. Family history of IHD (MI in 1st degree
relative <55yrs).
Modifiable
1. Smoking.
2. Hypertension.
3. DM.
4. Hyperlipidaemia.
5. Obesity.
6. Sedentary lifestyle.
7. Cocaine.
ANGINA PECTORIS
Angina pectoris
• Angina pectoris is the symptom complex
occurring when an imbalance between
myocardial oxygen supply and demand causes
transient myocardial ischemia.
• Stable angina:
Induced by effort and relieved by rest
• Angina is symptomatic reversible myocardial
ischaemia.
• Typical angina or typical chest pain:
1. Constricting/heavy discomfort to the chest,
jaw, neck, shoulders, or arms.
2. Symptoms brought on by exertion.
3. Symptoms relieved within 5min by rest or GTN.
• Interpretation :
• All 3 features = typical angina;
• 2 features = atypical angina
• 0–1 features = nonanginal chest pain.
• Other precipitants:
1. Emotion.
2. Cold weather.
3. Heavy meals.
• Associated symptoms:
• dyspnoea, nausea, sweatiness, faintness.
• Features that make angina less likely: pain that
is continuous, pleuritic or worse with
swallowing; pain associated with palpitations,
dizziness or tingling
Causes
1. Atheroma.
2. Anaemia.
3. Coronary artery spasm.
4. Aaortic stenosis (AS).
5. Tachyarrhythmias.
6. Hypertrophic caediomyopathy (HCM).
7. Arteritis/small vessel disease (microvascular
angina/cardiac syndrome X).
Variant (Prinzmetal’s) angina
• This is due to coronary artery spasm, which can
occur even in normal coronary arteries.
• Pain usually occurs during rest (rather than during
activity).
• ECG during pain shows ST segment elevation,
which resolves as the pain subsides.
• Patients usually do not have the standard risk
factors for atherosclerosis.
• Treatment:
• Calcium channel blockers.
:Decubitus angina
• Chest pain precipitated by lying flat
Investigations
• ECG:
• usually normal, but may show ST depression;
flat or inverted T waves; signs
• …………….. .
• other investigations to Exclude precipitating
factors: anaemia,diabetes, hyperlipidaemia,
thyrotoxicosis, temporal arteritis.
• Unstable (crescendo) angina:
• Angina of increasing frequency or severity
associated with increase risk of MI.
ACUTE CORONARY SYNDROM (ACS)
Differentiating ACS
Chest pain ?ACS
ECG
ST-elevation No ST-elevation
STEMI Troponin T
Raised Not raised
NSTEMI Unstable angina
Clinical presentation
• Symptoms
1. Chest pain.
• Acute central chest pain, lasting >20min, often
associated with nausea, sweatiness,
dyspnoea, palpitations.
• May present without chest pain (‘silent’
infarct), eg in the elderly or diabetics.
2. Syncope.
3. Pulmonary oedema.
4. Epigastric pain.
5. Vomiting.
6. Post-operative hypotension or oliguria.
7. Acute confusional state.
8. ……………………………..
Clinical presentation
• Signs:
1. Distress.
2. Anxiety.
3. Pallor.
4. Sweatiness.
5. Pulse rate (increase or decrease).
6. BP (increase or decrease).
7. Signs of heart failure ( JVP, 3rd heart sound,
basal crepitations)
ECG Troponin T
STEMI ST elevation Positive
NSTEMI ST -/+ Positive
depression
Unstable - Negative
angina
Investigations
ECG
Cardiac enzymes
The serial evolution of ECG changes in full-
thickness myocardial infarction
A. Normal.
B. (Minutes) Acute ST elevation.
C. Progressive loss
of the R wave developing
Q wave, resolution of the
ST elevation and terminal
T-wave inversion. (Hours)
D. D (Days)
Deep Qwave and
T-wave inversion
E. (Weeks or months)
Old or established infarct
Pattern the Q wave tends
to persist
but the T-wave changes
become less marked
Cardiac enzymes
• The plasma concentration of enzymes and
proteins normally concentrated within cardiac
cells is increased in MI.
• The most useful markers are creatine kinase
(CK) and CK-MB (a cardiospecific isoform) and
• The cardiac troponins T and I.
• CK starts to rise at 4–6 hrs, peaks at ~12 hrs
and falls to normal within 48–72 hrs.
Differential diagnosis
Cardiac Respiratory GI
• MI • Pulmonary • Oesophageal
• Angina embolism spasm
• Pericarditis • Pneumothorax • GORD
• Aortic • Pneumonia • Pancreatitis
dissection
MANAGMENT
Management
• No pharmacological
• Modify risk factors:
1. Stop smoking.
2. Encourage exercise.
3. Weight loss.
• Control hypertension.
• Control diabetes.
• Control hyperlipidemia.
Pharmacological
1. Antiplatelet
• Aspirin (75–150mg/24h) reduces mortality by
34%.
2. Beta blocker ex. Atenolol.
3. Nitrates.
4. Calcium channle blocker.
5. K+ channel activator, eg nicorandil .
Pre-hospital
• Arrange emergency ambulance.
• Aspirin 300mg chewed.
• GTN sublingual.
• Analgesia, eg morphine 5–10mg IV +
metoclopramide
Treatment
STEMI
1. Primary angioplasty or thrombolysis.
2. Beta-blocker.
3. ACE-inhibitor.
4. Clopidogrel
NSTEMI
1. Beta- blocker, eg atenolol 5mg IV and
nitrates IV unless contraindicated.
2. Anticoagulant heparin.
3. anti-platlets.
4. Lipid lowering agents statins
Complications
1. Cardiac arrest.
2. Cardiogenic shock
3. Bradycardias or heart block.
4. Tachyarrhythmias.
5. Pericarditis.
6. Mitral regurgitation
7. Ventricular septal defect
