Ischemic Heart Disease

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Ischemic Heart Disease (IHD coronary Heart
Disease)
Introduction to Primary Care a course of the
Center of Post Graduate Studies in FM
PO Box 27121 Riyadh 11417 Tel [phone] Fax
4970847
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objectives

• At the end of this session the trainee will be
  able to
• be able to discuss the burden of IHD.
• describe essential elements in history taking
  examination
• develop a differential diagnosis of chest pain.
• describe appropriate diagnostic testing for chest
  pain.
• discuss modifiable non modifiable risk factors
  for cardiac disease.
• describe the use of investigation in the
  evaluation of a patient with chest pain.
• appropriatly use of specialty referral.

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Prevalence of IHD

• Heart diseases responsible for overal deaths in
  the Saudi population
• IHD 17
• Hypertensive heart disease 9
• CVA 4

18th scientific session of the Saudi Heart
Association. 2007 http//www.highbeam.com/doc/1G1-
158905180.html 
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History taking in CAD

• Patient characteristics (Name, age,
  sex,occupation)
• Pain (duration, location, intensity,nature,aggrava
  ting factors
• Associated symptoms (Dyspnea, syncope.etc)
• Past history (HPN,DM,COPD..ETC)
• Family history (coronary artery disease
  ,pneumothorax)
• Drug history (antiangina,anti diabetic..etc)
• Life style (Diet, exercise, alcohol, smoking )
• Psychosocial (ICE, anxiety, stress )

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What characteristics of the chest pain might
make you more concerned for cardiac chest pain?

• Location
• Associated Symptoms
• Quality
• Chronology
• Onset

• Duration
• Intensity
• Exacerbating
• Relieving
• Situation

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Physical Examination

• General Examination
• patient status stable,notstable,inpain or not in
  pain.
• Vital signs.
• Obese or overweight.
• Skin appearance.
• Cardiovascular respiratory system examination
• BP, Pulse rate, JVP.
• Chest apex beat deviation, crepitations,
  decrease breath sounds.
• Heart 1st 2nd heart sounds, gallop, friction
  rub.
• Abdomen tenderness, guadring.

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Any exam findings that might help distinguish
cardiac from non cardiac chest pain?

• General Appearance
• may suggest seriousness of symptoms.
• Vital signs
• marked difference in blood pressure between arms
  suggests aortic dissection
• Palpate the chest wall
• Hyperesthesia may be due to herpes zoster

• Complete cardiac examination
• pericardial rub
• Ischemia may result in MI murmur, S4 or S3
• Determine if breath sounds are symmetric and if
  wheezes, crackles or evidence of consolidation

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What would be the differential diagnosis
for chest pain?
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Life threatening Causes Non-life threatening Causes
Cardiovascular(16) Myocardial infarct. Angina. Thoracic aortic dissection. Pulmonary (5) Pulmonary embolus. Pulmonary infarction. Tension pneumothorax. Pneumonia. Pleurisy. Chest wall (33) Trauma Fracture Costo-chondritis. Musculoskeletal. Gastrointistinal(20) Esophageal spasm Esophagitis. Gall bladder disease. Peptic ulcer disease. pancreatitis Psychatric (9) Anxiety. Spinal dysfunction Cervical disease. Infections (rare) Herpes Zoster.
..
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The risk factors for CAD

• Age gt 45 (male) and gt55 (female).
• Smoking.
• Family history.
• Hyperlipidemia.
• Diabetes.
• Hypertension.
• Obesity.
• Sedentary life style.
• Anxiety.
• Drug addiction.
• Past History.

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Any tests that might help in diagnosis?

• History and Examination
• ECG
• Cardiac Enzymes
• Chest x-ray.
• Upper GI endoscopy.

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Cont

• ECG
• ST elevation of gt 1mm or new Q in 2 leads
• Sensitivity 45
• Above ST depression or T-wave inversion
• Sensitivity 79
• False positive rate 17
• 20 of patients having an MI will have a normal
  ECG initally

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Cont

• Cardiac enzymes
• Troponin, CK, myoglobin
• 88-90 sensitive at 4-6 hours
• 95-100 sensitive 8-12 hours

Source Am Heart J 1998 Aug136(2)237-44
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Risk Category LDL Goal(mg/dL) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Level at Which to ConsiderDrug Therapy (mg/dL)
CHD or CHD Risk Equivalents(10-year risk gt20) Very high risk lt100 lt70 (VHRP) ?100 ?130 (100129 drug optional) (lt 100 drug optional)
2 Risk Factors (10-year risk ?20) (moderately high risk pt ) 10-year risk lt 10 lt130 lt100(theraputic option) lt130 ?100 ?130 10-year risk 1020 ?130 100-129 10-year risk lt10 ?160
01 Risk Factor lt160 ?160 ?190 (160189 LDL-lowering drug optional)
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• Diabetes is regarded as a CHD Risk Equivalent
• 10-year risk for CHD ? 20
• High mortality with established CHD
• High mortality with acute MI
• High mortality post acute MI

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Initial Approach

• ABC assessment
• 100 Oxygen
• Aspirine
• Nitroglycerine
• IV access
• Morphine
• Monitoring
• ECG quickly

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Action Plan
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Action Plan
Source http//www.aafp.org/afp/20050701/119.html
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Referral

• Refer urgently all the serious conditions with
  chest pain
• Cardiac causes.
• Esophageal spasm.
• Pulmonary embolism.
• Any other cases not responding to usual treatment.

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Important Points

• The likelihood of acute coronary syndrome (low,
  intermediate, high) should be determined in all
  patients who present with chest pain.
• A 12-lead ECG should be obtained within 10
  minutes of presentation in patients with ongoing
  chest pain.
• Cardiac markers (troponin T, troponin I, and/or
  creatine kinase-MB isoenzyme of creatine kinase)
  should be measured in any patient who has chest
  pain consistent with acute coronary syndrome.

http//www.aafp.org/afp/20050701/119.html
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Important Points

• A normal electrocardiogram does not rule out
  acute coronary syndrome.
• When used by trained physicians, the Acute
  Cardiac Ischemia Time-Insensitive Predictive
  Instrument (a computerized, decision-making
  program built into the electrocardiogram machine)
  results in a significant reduction in hospital
  admissions of patients who do not have acute
  coronary syndrome.

http//www.aafp.org/afp/20050701/119.html
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