Title: Ischaemic Heart Disease. Coronary Heart Disease.
1Ischaemic Heart Disease.Coronary Heart Disease.
2- Atheroma of the coronary arteries
- The commonest cause of changes in the luminal
diameter of the coronary arteries is the presence
of atheromatous plaques. - The lesions may encircle an artery or may be
eccentric they may be discrete and localised or
involve the greater length of the vessel. - Acute changes in the plaques may account for
unstable angina,myocardial infarction and sudden
death.,because expansion of the lesion occurs
when the endothelial cells rupture,allowing
haemorrhage into the plaque and platelet
aggregation on the endothelial surface.
3- Clinical feasture
- Symptoms
- The cardinal symptom is angina pectoris. This is
a chest discomfort precipited by exertion and
relieved by rest. It is often descriped as a
pressing or constricting feeling. - The patient may hold a clenched fist in front of
the sternum to indicate the squeezing nature of
the pain,and may describe radiating discomfort in
the left arm and jaw,or even a choking sensation
in the throat.
4- Dyspnoea frequently accompanies angina.
- There is usually rapid relief of the symptom with
sublingual nitrate tablets. - The pain of myocardial infarction may be similar,
but generally begins at rest ,does not respond so
well to nitrates, lasts longer than 20 minutes
and is often associated with feeling of impending
death,nausea,sweating and collapse. - Unfortunately, in many patients with I H D ,the
first manifestation of disease may be sudden
death. Prevention of atheroma is necessary to
reduce this.
5- Signs
- There are few physical findings in uncomplicated
I H D. - There may be evidence of hypertension or
hyperlipidaemia - .
- Cardiac dilatation,hypertrophy ,and failure are
all late features and are non-specific. - .Auscultation may reveals a fourth and third
heart sounds over the apex in Pt complicated with
Lt vent .faliure. - Orthopnoea,and fine basal crackles are present in
Pt developing pulmonary oedema. - Some individuals have significant ischaemic
episodes without symptoms.This may discovered by
routine ECG.
6Other anginal syndromes
- The previous is a desciption of typical
angina.Several other anginal syndromes occur
which are less common. - 1-Crescendo angina and unstable angina
- Both represent a state of preinfarction.In
crescendo angina, a history of increasingly
frequent attacks of angina with ever-diminishing
levels of exertion is obtained.Unstable angina
includes situations where episodes of pain are
frequent,may occure without obvious cause and at
rest. - Decubitus angina is angina occuring at rest in
bed.
7- 2-Vasospastic angina
- Some degree of arterial spasm is probably present
in most episodes of angina, but spasm on normal
coronary can occur(rarely),this spasm can be
sever enough to cause infarction. - In Prinzmetals syndrome,rest pain is associated
with acute ST segment elevation which resolves to
normal with cessation of pain. - This condition is rare and almost involves
coronary vasospasm.
8Differential Diagnosis of Angina
- With all causes of chest pain
- 1-Angina pectoris.
- 2-Angina due to Aortic valve stenosis.
- 3-Acute Myocardial infarction.
- 4-Aortic dissection.
- 5-Acute pericarditis.
- 6-Oesophageal spasm.
9Chest Pain
- 1-Cardiac ischemic pain
- In a typical case the discomfort associated with
myocardial ischemia is described as a compression
or tightness in the chest which may also be felt
in the throat, producing the choking feeling
being called angina pectoris. - Siteretrosternal.
- Radiationleft side ,jaw ,arm,and forearm.
10- The precipitating causes are typically those
which will increase myocardial oxygen demand
beyond the coronary .Excersion ,Emotional upsets
,Cold . - What increaseEmotions,stress,cold.
- What decreaseRest,Nitroglycerin GTN.
- Durationless than 10 minutes.
- Special types of anginaUnstable angina
it is more sever form of angina,if untreated
can lead to myocardial infarction.
11- Myocardial infarction
- It causes pain similar to angina in
site,radiation and character but it is usually
more sever and prolonged and persists despite
taking glycerin trinitrate. - Autonomic symptoms usually in association
,sweating ,irritability,palpitation ,nausea,and
,vomiting are common ,particularly in inferior
wall infarction. Pt. may also be
breathless,restless with sensation of impending
death. - With acute anterior infarction,tendency for
sympathetic activity to dominate,--tachycardia,coo
l pale periphery and normal or even slightly high
Bl.pressure in early minutes.This contrasts with
acute inferior infarction,which associated with
massive vagal discharge ,producing a cold sweaty
periphery,bradycardia,hypotension,nausea and
vomiting.
12- Painless or silent myocardial infarction is not
uncommon,particularly in diabetic patient and the
elderly. -
- This patients may present later with
complications from their infarct such as cardiac
faliure or an arrhythmia , diagnosis may be made
retrospectively from routine electrocardiogram
(ECG).
13- Pericardial pain
- Chest pain is usually more localized than
ischemic pain. - Site retrosternal,may radiate to Lt shoulder.
- Prodromamay be preceded by viral illness.
- Naturestabbing and sharp.
- Made worse by change in posture,respiration.
- Helped by analgesics.,and NSAIDS.
- Accompanied by pericardial rub.
14- Aortic dissection
- The sudden development of a linear tear in the
wall of the aorta is called acute dissection. - The length of aorta affected varies from a few
centimetres to the whole vessel. - Siteretrosternal.
- Onsetsudden.
- Naturevery sever ,tearing pain.
- Relived byNo ,tend to persist.
- Accompanied by Hypertension,Syncope.sweating,.
15- Risk factors for coronary Ht disease
- 1-Age increased in older age due to
atherosclerosis. - 2-Male sex .
- 3-Postive family history of IHD.
- 4-Hypertension.
- 5-Hyperlipidaemia.
- 6-Diabetes mellitus.
- 7-Obesity.
- 8-Lack of exercise.
16Investigations1-in angina
- 1-Resting ECG
- Recording the electrical activity of the
heart ,usually normal in between attacks ,in
attack it may show ST segment depression,T wave
inversion. - 2-Excerise ECG
- It is recorded whilst the patient walks or run
on motorized treadmill or cycles.If there is ve
history of chest pain and ve resting ECG you can
do stress ECG,it will be very useful to confirm
the diagnosis.
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22- 3-Cardiac scintigraphyOr Nuclear imaging
- Myocardial perfusion scan at rest and with
exercise,using contrast like thallium, - (Th -201) is rapidly taken immediately after IV
injection,reflects the distribution of blood flow
to the myocardium--areas of decreased myocardial
perfusion means ischemia.(receive less thallium). - 4-EchocardiographyUse echoes of ultrasound waves
to map the heart and study its functions.This can
be used to assess ventricular wall
involvement..and vent.function,
23- Regional wall motion abnormalities at rest
reflect previous ventricular damage. - 5-Coronary angiography
- This is occasionally usefull in Pt with chest
pain and the diagnosis is un clear.This can be
done through cardiac catheterisation. - Coronary angiography is performed using catheters
designed to select Lt and Rt coronary
artery,inject X- ray contrast medium.,then the
coronaries can be visualized. - it is usefull because it shows the exact coronary
affected ,with narrowing or obstruction .
24Normal coronary angiography.
25Coronary narrowing.
26Treatement of angina
- 1-Treatment of risk factors
- Hypertension ,DM,Obesity,stop
smoking.Hyperlipidemia. - 2-Medical treatement
- 1- VasodilatorsNitrates
- .Glyceryl trinitrate(GTN)-tablets,and,skin
patches. - Isosorbide dinitrate(oral,short
actingsustained release) - Isosorbide mononitrates-(oral some SR)
- 2- Beta blockers.
- Atenolol(B1-selective)
- Propranolol(non-selective.both tacken orally..
- 3- Calcium channel blockers.Nifedipin,Diltiazem,
Verapamil. - 3-Surgical Coronary artery bypass grafting and
angioplasty.
27Treatment of unstable angin
- 1-ICU admission.
- 2-Bed rest and light sedation.
- 3-Oxygen.
- 4-Low dose aspirin.antiplatlet aggregator.
- 5-Heparin IV ,to minimise thrombus formation.
- 6-Nitrates (buccal or iv)
- 7-Close monitoring of blood pressure during
nitrate infusion.care about hypotension. - 8-B-blockers and Ca antagonists may be added when
needed.
28- In vasospastic or prinzmetal angina,the aim of
treatment is to prevent the powerful
vasoconstriction - Combination therapy using long acting isosorbide
mononitrate,calcium antagonists. - Beta-blockers may have to be added to counteract
the reflex tachycardia and reduce the intensity
of angina by reducing 02 demand during the attack.
29- Investigations in acute MI
- 1-ECG Q-wave ,and riased ST segment in affected
leads. - 2-Cardiac enzymes
- Creatinin kinase CK --CK-MB(cardiac
specific).increased withen few hours,and
decreased in 24-48 hours. - Cardiac-specific troponins Troponin I .,are
regulatory proteins,increased in cardiac injury. - Lactate dehydrogenase ( LDH)appers withen 12-24
hours,and disappered late. - 3-A raised polymorphonuclear leucocyte count and
elevated (ESR) are non specific companiments of
acute MI.
30Treatment of acute MI
- Acute management
- Analgesia and oxygen,bed rest.
- .
- If acute MI diagnosed ,Thrombolysis must be done
with out delay .Six hours is the time limit
withen which it is possible that measures to
restore Bl.supply. - Thrombolytic treatement can achieve reperfusion
in 50-70 of patients,and usually reduces the
extent of ventricular damage and mortality rate. - Streptokinase (1.5 million units over one hour)
is the agent most commonly used. - .
31Asiprin ,as an antiplateletes,150 mg
chewed. Heparin. Nitrates,by infusion early
,later on we can use skin patches. B-blockers,-de
creased the rate of cardiac deathes. Follow up.
32Complications of acute MI
- Acute complications
- 1-Very early after infarction,all kinds of
cardiac arrhythmia can occur like - Ventricular extrasystoles
- Ventricular tachycardia
- Ventricular fibrillation.
- Atrial fibrillation.
- Sinus tachy or bradycardia.
- Conduction disturbance.
33- 2-Cardiac failure.
- 3-Cardiogenic shock.
- 4-Thromboembolism ,due to Lt ventricular mural
thrombus may form on the endocardial surface of
the infarcted region. - 5-Acute ventricular septal rupture and ruptured
papillary muscle.Treatment is early surgery for
both.
34- Late complications
- 1-Pericarditiscan occure after MI as an early
complicationoccur days after infarction,clinicall
y sharp chest pain aggrevated by movement. - 2-Post myocardial infarction syndrome(Dressler
syndrome) - Late complicationIt is an autoimmune
pericarditis ,(antibodies aginst cardiac myocytes
were detected) occur weaks or months after
infarction consists of pericarditis, fever,high
ESR, and pericardial effusion.,treated by
NSAIDs,and corticosteroids.Prognosis is good. - 3-Left ventricular aneurysm .