Ischaemic Heart Disease. Coronary Heart Disease.

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Ischaemic Heart Disease.Coronary Heart Disease.
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• 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.

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• 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.

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• 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.

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• 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.

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Other 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.

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• 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.

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Differential 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.

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Chest 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.

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• 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.

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• 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.

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• 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).

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• 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.

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• 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,.

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• 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.

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Investigations1-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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• 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,

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• 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 .

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Normal coronary angiography.
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Coronary narrowing.
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Treatement 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.

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Treatment 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.

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• 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.

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• 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.

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Treatment 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.
• .

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Asiprin ,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.
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Complications 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.

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• 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.

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• 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 .