Ischemic Heart Disease (IHD) PDF

Ischemic Heart Disease (IHD) By Dr-Mohamed Hassan Kamel (MD) Lecturer of internal medicine Al-Azhar faculty of medicine Blood supply of the heart  The heart is supplied by 2 coronaries (Rt. & Lt.) , which encircle the heart like a crown. Origin : from aortic si...

Ischemic Heart Disease (IHD) By Dr-Mohamed Hassan Kamel (MD) Lecturer of internal medicine Al-Azhar faculty of medicine Blood supply of the heart  The heart is supplied by 2 coronaries (Rt. & Lt.) , which encircle the heart like a crown. Origin : from aortic sinus of ascending aorta. Rt. coronary gives 2 branches (rt. marginal and posterior inter-ventricular ) Lt. coronary gives 2 branches : ( marginal or called circumflex (LCX) and anterior inter-ventricular or called lt. anterior descending (LAD ). Rt. coronary anastomoses with circumflex branch of lt. coronary. Definition of IHD  Ischemic heart disease is a“Condition causing hypoxia to the myocardium due to inadequate perfusion secondary to varied etiology” Atherosclerosis of epicardial arteries :– the commonest cause IHD is considered one of the commonest cause of morbidity /mortality. Modes of presentation  Silent ischemia Stable angina pectoris Unstable angina Myocardial infarction Heart failure Arrhythmia Sudden death  Types of IHD Angina pectoris -Chronic stable angina -Unstable angina Acute myocardial infarction RISK FACTORS  MODIFIABLE Cigarette Smoking Obesity Hypertension Hypercholesterolemia Diabetes mellitus Mental Stress & Physical Inactivity Contraceptive pills  NON MODIFIABLE Genetic Sex Age Causes  Arteriosclerosis (Thickening and hardening of arterial walls ) Atherosclerosis Calcification Inflammatory Granulomatous Autoimmune  Atherosclerosis (Patchy nodular type of arteriosclerosis ) Fatty streak–Earliest lesion ,yellow /white patch in intima of aorta’ , Reversible Fibrous plaque –‘firm , elevated dome shaped lesion’, ‘seen in aorta/coronaries/carotids indicates advancing atherosclerosis Complicated lesion –‘calcified fibrous plaque’ with necrosis ,thrombosis ,ulceration > causing obstruction to lumen/trigger plaque rupture  Arteritis Systemic lupus erythematosus(SLE) Rheumatoid arthritis(RA)  Embolism Infective endocarditis Left atrial /ventricular thrombus Left atrial/ventricular tumor Prosthetic valve thrombus Complication of cardiac catheterization  Coronary mural thickening Amyloidosis Radiation therapy Coronary luminal narrowing Aortic dissection Coronary spasm  ANGINA PECTORIS Definition “discomfort felt in the chest or around chest due to myocardial ischemia due to decreased coronary blood flow or a mismatch between myocardial O2 supply and demand” Causes of angina Reduced myocardial oxygen supply Coronary artery disease -Atherosclerosis -Arteriosclerosis Severe anemia -Bleeding -Hemolysis Increased myocardial Oxygen demand Left ventricular hypertrophy -Hypertension -Aortic stenosis -Aortic regurgitation -Hypertrophic cardiomyopathy Rapid tachy arrhythmias -Acute atrial fibrillation -Ventricular tachycardia Types of angina  Classic angina- Sudden ,sharp ,left sided chest pain ,retrosternal ,varying intensity, radiation to left arm ,jaw ,neck ,forearm, any quality, 5- 10 min , on work and exercise , relieve d by rest \sublingual nitrates Atypical angina- absence of one or more criteria ( may not on work or by rest)  Angina equivalent– Dyspnea as a main manifestation Variant (prinzmetal angina )– Angina at rest\periodic with ST segment elevation on ECG.  Angina decubitus – Angina in recumbent position ( lying down ) Nocturnal angina– angina at night ( like Paroxysmal nocturnal dyspnea ) Angina inversus – Pain increases at rest and decreases on exercise  Symptoms Typical /atypical chest pain Chest discomfort Breathlessness Silent Congestive cardiac failure (CCF) Malignant Ventricular tachycardia Sudden death  Conditions that provoke ischemia Hyperthyroidism Hypertension Hyperthermia Anxiety Renal disease Severe anemia Aortic stenosis Arrhythmias Hypoxemia Polycythemia Clinical examination  Look for risk factors Systemic disease :DM/HTN/ Thyroid/anemia BP /Peripheral arteries /LVH Cardiac auscultation:S3 /S4 /murmurs /clicks Investigations  ECG -12 lead ECG CXR Treadmill test (TMT) 2D Echo Cardiac CT /MRI Coronary angiography Blood chemistry :Blood sugar ,lipid profile, cardiac enzymes (CK , CKMB, Troponin ) , CBC, Coagulation and bleeding profile. ECG in angina  Normal ECG does not rule out IHD ST Segment depression ,T wave inversion are the usual features ST elevation –prinzmetal angina /early MI Stress ECG–ST depression Normal ECG Management  Non pharmacological Patient education–risk factors Weight reduction Smoking and alcohol cessation Avoid and decrease stress/anxiety Regular exercise: 30 minutes /day Control comorbid conditions (DM,HTN,DLP )  Pharmacological Treat hyperlipidemia Diet /exercise /drugs–Statins Goal –Total cholesterol