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Questions and Answers

What are the three broad categories of aetiology for Ischaemic Heart Disease (IHD)?

  • Transmural infarction, Subendocardial infarction, STEMI
  • Coronary artery disease, Myocardial infarction, Angina pectoris
  • Fixed coronary obstruction, Acute plaque changes, Sudden cardiac death
  • Coronary atherosclerosis, Superadded changes in coronary atherosclerosis, Non-atherosclerotic causes (correct)

    • Which of the following is NOT a clinical presentation of IHD?

  • Stenosis of coronary ostia (correct)
  • Angina pectoris
  • Sudden cardiac death
  • Myocardial infarction
  • Chronic IHD with congestive heart failure

    • Ischaemic Heart Disease (IHD) is defined as an acute or chronic form of cardiac disability arising from an imbalance between the myocardial blood supply and demand for oxygenated blood and nutrients.

    True

    What is the most common cause of myocardial anoxia?

    <p>Narrowing or obstruction of the coronary arterial system</p> Signup and view all the answers

    What is the leading cause of death in most developed countries?

    <p>Ischaemic Heart Disease</p> Signup and view all the answers

    The incidence of Ischaemic Heart Disease (IHD) is observed to be higher in developing countries.

    <p>False</p> Signup and view all the answers

    Men develop IHD earlier than women and death rates are also slightly higher for men until the menopause.

    <p>True</p> Signup and view all the answers

    Atherosclerosis is responsible for less than 10% of cases of IHD.

    <p>False</p> Signup and view all the answers

    What is the most prevalent cause of IHD?

    <p>Atherosclerosis</p> Signup and view all the answers

    What is the primary mechanism for the development of fixed coronary obstruction?

    <p>Atherosclerosis</p> Signup and view all the answers

    What is the typical percentage of coronary stenosis that leads to stable angina?

    <p>70%</p> Signup and view all the answers

    Which of the following is the most common location for significant myocardial ischemia in coronary atherosclerosis?

    <p>Left Anterior Descending Artery</p> Signup and view all the answers

    Superadded changes in coronary atherosclerosis refer to acute changes in atheromatous plaques, such as plaque haemorrhage, fissuring or ulceration.

    <p>True</p> Signup and view all the answers

    Sudden coronary artery spasm, tachycardia, intraplaque hemorrhage, and hypercholesterolemia are factors that can contribute to superadded changes in coronary atherosclerosis.

    <p>True</p> Signup and view all the answers

    Coronary artery thrombosis is initiated by the formation of a thrombus on the surface of a fixed atheromatous plaque.

    <p>True</p> Signup and view all the answers

    Local platelet aggregation and coronary artery spasm are NOT contributing factors to superadded changes in coronary atherosclerosis.

    <p>False</p> Signup and view all the answers

    Vasospasm is the only non-atherosclerotic cause of IHD.

    <p>False</p> Signup and view all the answers

    Syphilis can contribute to Stenosis of coronary ostia.

    <p>True</p> Signup and view all the answers

    Aortic atherosclerotic plaques can encroach on the opening of coronary arteries, resulting in Stenosis of coronary ostia.

    <p>True</p> Signup and view all the answers

    Arteritis refers to inflammatory involvement of coronary arteries or small branches, and is a non-atherosclerotic cause of IHD.

    <p>True</p> Signup and view all the answers

    Rheumatic arteritis, polyarteritis nodosa and other bacterial infections can also contribute to myocardial damage in addition to contributing to arteritis.

    <p>True</p> Signup and view all the answers

    Embolism, a non-atherosclerotic cause of IHD, refers to emboli originating from elsewhere in the body.

    <p>True</p> Signup and view all the answers

    Thrombotic disease is a common cause of IHD.

    <p>False</p> Signup and view all the answers

    Trauma can cause IHD through contusion of a coronary artery from penetrating injuries.

    <p>True</p> Signup and view all the answers

    Aneurysms are a common cause of IHD.

    <p>False</p> Signup and view all the answers

    Compression from outside by a primary or secondary tumor of the heart can cause IHD.

    <p>True</p> Signup and view all the answers

    Angina pectoris is characterized by chest pain that is insufficient to cause myocyte death.

    <p>True</p> Signup and view all the answers

    Myocardial infarction is characterized by chest pain caused by myocardial ischemia that is sufficient to cause cardiomyocyte death.

    <p>True</p> Signup and view all the answers

    Chronic IHD with congestive heart failure is a condition that develops after myocardial infarction.

    <p>True</p> Signup and view all the answers

    Sudden cardiac death is typically caused by a lethal arrhythmia following myocardial infarction.

    <p>True</p> Signup and view all the answers

    Which of the following clinical patterns of angina pectoris is referred to as "pre-infarction angina" or "acute coronary insufficiency"?

    <p>Unstable angina</p> Signup and view all the answers

    Which of the following clinical patterns of angina pectoris is characterized by pain at rest, with no relationship to physical activity?

    <p>Prinzmetal angina</p> Signup and view all the answers

    Prinzmetal angina is characterized by ST segment elevation on ECG.

    <p>True</p> Signup and view all the answers

    Acute myocardial infarction accounts for 10-25% of all deaths.

    <p>True</p> Signup and view all the answers

    The incidence of acute myocardial infarction is higher in women during the reproductive period.

    <p>False</p> Signup and view all the answers

    Which of the following is NOT a cause of acute myocardial infarction?

    <p>Increased oxygen demand</p> Signup and view all the answers

    Acute plaque changes, such as superimposed thrombosis and vasospasm, can lead to acute myocardial infarction.

    <p>True</p> Signup and view all the answers

    Platelet aggregation and coronary artery spasm have no role in the development of acute myocardial infarction.

    <p>False</p> Signup and view all the answers

    The most vulnerable area of the myocardium to hypoxia and hypoperfusion is the endocardium.

    <p>False</p> Signup and view all the answers

    Acute coronary syndrome refers to a group of conditions that include unstable angina, acute MI, and sudden cardiac death.

    <p>True</p> Signup and view all the answers

    The most common location for myocardial infarction is in the left ventricle.

    <p>True</p> Signup and view all the answers

    Transmural infarction involves the full thickness of the ventricle.

    <p>True</p> Signup and view all the answers

    Which type of myocardial infarction is associated with ST segment elevation on ECG?

    <p>Transmural infarction</p> Signup and view all the answers

    Subendocardial infarction is characterized by ST segment depression and T-wave inversion on ECG.

    <p>True</p> Signup and view all the answers

    Study Notes

    Ischemic Heart Disease and Myocardial Infarction 1

    • Learning Outcomes (Ischemic Heart Disease):

      • Define and classify ischemic heart disease (C3)
      • Describe the pathogenesis of ischemic heart disease (C2)
      • Explain the types of angina pectoris (C2)

    • Learning Outcomes (Myocardial Infarction):

      • Describe the pathophysiology of myocardial infarction (subendocardial and transmural infarction, STEMI, non-STEMI) (C2)
      • Describe the clinical features of acute myocardial infarction (C2)

    Anatomy of the Heart

    • The right coronary artery (RCA) supplies the right atrium, right ventricle, lower part of the left ventricle, and back of the septum
    • The left coronary artery (LCA) has two main branches, the left circumflex artery (LCX) and the left anterior descending artery (LAD)
    • The LCX supplies the left atrium and sides/back of the left ventricle
    • The LAD supplies the front and bottom of the left ventricle and front of the septum.
    • Coronary veins carry deoxygenated blood back to the heart.

    Phases of the Cardiac Cycle

    • Atrial Systole: Atria contract, pushing blood into ventricles
    • Ventricular Systole (Phase 1): Ventricles contract, closing AV valves
    • Ventricular Systole (Phase 2): Semilunar valves open, blood ejected
    • Ventricular Diastole (Phase 1): Semilunar valves close
    • Ventricular Diastole (Phase 2): Chambers relax, blood passively fills

    Ischemic Heart Disease (IHD)

    • Defined as an acute or chronic form of cardiac disability due to an imbalance in myocardial blood supply (perfusion) and oxygen demand.
    • Coronary artery disease (CAD) is a synonymous term for IHD
    • IHD is the leading cause of death in developed countries, while incidence is lower in developing countries.
    • Men are typically affected at an earlier age than women.

    IHD - Aetiopathogenesis

    • Coronary Atherosclerosis:
      • Most prevalent cause (90%).
      • Affecting one or more of the major coronary arteries (LAD, RCA, LCX)
      • Narrowing of coronary arteries is typically significant (75%) near the ostia, which are the origins of the arteries.
    • Atherosclerosis (Superadded changes):
      • Plaque hemorrhage, fissuring, or ulceration leading to thrombus.
      • May be worsened by factors such as spasm, tachycardia, or hypercholesterolemia.
      • Coronary artery thrombosis leads to significant luminal blockage
    • Non-atherosclerotic causes:
      • Vasospasm
      • Stenosis of coronary ostia from extension of syphilitic aortitis or from aortic atherosclerotic plaques.
      • Arteritis (inflammatory issues) like rheumatic arteritis, polyarteritis nodosa, thrombo-angiitis obliterans, Takayasu disease, tuberculosis.
      • Embolization from elsewhere in the body
      • Thrombotic disorders
      • Trauma, aneurysms, tumor compression

    Clinical Presentations of IHD

    • Angina Pectoris: Chest pain due to transient myocardial ischemia

    • Myocardial infarction (MI): Sufficient ischemia causes cardiomyocyte death

    • Chronic IHD with congestive heart failure: Progressive cardiac decompensation from MI

    • Sudden cardiac death (SCD): Post-MI lethal arrhythmia

    Angina Pectoris

    • Intermittent chest pain caused by transient ischemia. Pain is worsened by increased demand and relieved by decreased demand.
    • Pain often described as squeezing, pressure, fullness or tightness in the center of the chest. Often spreading to the neck, jaw, shoulder, or arm.

    Stable Angina

    • Most common type
    • Pain triggered by exertion or stress, relieved by rest.
    • Demonstrates ST depression on EKG.

    Unstable Angina

    • Most serious angina type
    • More frequent, occurring at rest.
    • Indicates impending acute MI
    • Due to plaque disruption, thrombosis, or vasospasm

    Prinzmetal Angina

    • Pain is independent of exertion or stress.
    • Likely due to coronary vasospasm.
    • May respond to nitroglycerine or calcium channel blockers .

    Acute Myocardial Infarction (MI)

    • 10-25% of deaths are caused by MI and is characterized by coagulative necrosis of heart muscle. Occurs due to decreased blood supply to the heart. This can be due to atherosclerotic plaques or spasms.

    • Causes:

      • Coronary artery disease and atherosclerosis.
      • Increased demand (e.g., hypertension, high heart rate)
      • Reduced blood volume (hypotension or shock)
      • Reduced oxygenation (e.g., pneumonia, heart failure)
      • Reduced oxygen capacity (e.g., anemia, carbon monoxide poisoning)

    • Clinical Features: Severe crushing substernal chest pain that radiates (spreads) to the arm/jaw/neck. The pain may last several minutes and commonly occurs with sweating, nausea, dyspnea, and a weak pulse.

    Types of MI

    • Transmural MI (STEMI): Full-thickness cardiac muscle injury. Associated with ST-segment elevation and Q-wave formation on ECG.

    • Subendocardial MI (NSTEMI): Limited to the inner third of the cardiac muscle wall. No ST-segment elevation but possible ST depression or T-wave inversion on ECG.

    Distribution of Myocardial Infarction

    • Left anterior descending artery (LAD): Anterior wall of the left ventricle, anterior interventricular septum, apex. (40-50%)
    • Right coronary artery (RCA): Inferior wall of the left ventricle , right ventricle (30-40%)
    • Left circumflex artery (LCX): Lateral wall of the left ventricle (20%)

    MI Classification

    • Anatomical region of LV involved.
    • Degree of ventricular wall involved ( Full thickness/subendocardial)
    • Age of MI (acute/fresh, healed/organized)

    Pathogenesis of IHD and MI

    • Acute changes like rupture, fissuring, or ulceration of atherosclerotic plaques.
    • Expose thrombogenic components to the subendothelium.
    • Can lead to acute coronary syndromes, including unstable angina, MI, and sudden cardiac death.

    Factors affecting acute plaque change:

    • Intrinsic factors (plaque composition)
    • Extrinsic factors (stress/emotions)

    Acute Coronary Syndrome

    • Includes unstable angina, acute MI, and sudden cardiac death. -Caused by a plaque change

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