CAD and HF part 1.docx

Coronary artery diseases (CAD) Etiology: Atherosclerotic: 80-90 % of cases Non atherosclerotic Coronary embolization: Infective endocarditis Atrial fibrillation Collagen Vascular disease affecting the coronary artery: Systemic lupus erytherrmatosis Radiation therapy Risk factors of coron...

Coronary artery diseases (CAD) Etiology: Atherosclerotic: 80-90 % of cases Non atherosclerotic Coronary embolization: Infective endocarditis Atrial fibrillation Collagen Vascular disease affecting the coronary artery: Systemic lupus erytherrmatosis Radiation therapy Risk factors of coronary artery disease: Non modifiable risk factors: Positive family history Advanced age Male gender Genetic Modifiable risk factors: Physical inactivity Cigarette smoking Diabetes mellitus Insulin resistance & metabolic syndrome Hypertension Elevated lipid levels Stress Alcohol consumption Primary & Secondary Prevention of CHD Exercise daily 30 minutes smoking cessation, treatment of dyslipidemia, Lowering LDL levels delays the progression of athero­sclerosis and in some cases may produce regression lowering of BP Anti platelets as aspirin 81-325 mg/day Path physiology of angina pectoris and myocardial infarction: Imbalance between oxygen demand and oxygen supply Increase oxygen demand: exercise, stress,... Decreased oxygen supply: coronary spasm, platelet aggregation, thrombosis Angina pectoris: Acute chest pain due to imbalance between myocardial oxygen supply and myocardial oxygen demands Etiology: Coronary artery vasospasm Partial occlusion of the artery Clinical presentation: Pain is Squeezing, Crushing, stabbing, Heaviness, sense of Tightness Pain/Discomfort may radiate to shoulders, arms, neck, back, jaw or epigastrium Lasts for 3-5 min and rarely exceeds 15 min ≠ myocardial infarction where > 20 min Not changed by swallowing, coughing, deep breathing or positional changes Precipitated by exercise , Exposure to cold, anxiety, heavy meals, emotional stress Relieved by: rest, nitroglycerin ( vasodilator) Associated with : pallor, Shortness of breath, Weakness, Diaphoresis or clammy skin, nausea, vomiting, palpitation, hypotension/hypertension, syncope Differential diagnosis of chest pain: Cardiac Acute coronary syndrome Angina pectoris Myocardial infarction  Aortic dissection  Pericarditis  Myocarditis Respiratory Pulmonary embolism Spontaneous Pneumothorax &Tension pneumothorax Pleurisy  Gastrointestinal Gastroesophageal reflux disease (GERD) , Esophagitis, peptic ulcer, chronic cholecystitis Chest wall disease: osteochondritis of the costochondral junction Spinal nerve problem Chest wall problems Herpes zoster  Psychological Panic attack Anxiety Types of angina Stable angina: due to luminal narrowing, usually relived by rest/ nitroglycerine which act as vasodilator Unstable angina: more severe, more prolonged, more frequent, or may occur at rest Prinzmetal ( variant) angina: coronary vasospasm, due to hyperactivity of the sympathetic system or increased calcium influx into the artery Investigations Laboratory: Lipids profile, glycemic status, homocysteine levels Electrocardiogram ( ECG) Stress Electrocardiogram Echocardiography to asses segmental wall motion abnormalities & assessment of ventricular function Coronary angiography Treatment: Of the acute attack: short acting nitrates – sublingual (if pain doesn’t relief after three tablets or it persists more than 20 minutes , it may denote evolving myocardial infarction, needs emergent hospitalization) Prevention of further attacks: Long acting nitrates: e.g isosorbide mono & di nitrates Beta blockers: decrease myocardial oxygen requirements Calcium channel blockers: decrease myocardial oxygen requirements & induces vasodilatation Angiotensin converting enzyme inhibitors( ACEI) Platelet inhibiting agents Aspirin, Clopidogrel II a/IIIb Revascularization:( intervention ) Percutaneous trans luminal coronary angioplasty ( PCI) and stenting Coronary artery bypass graft ( CABG) Myocardial infarction (MI) Necrosis of area of myocardium due to inadequate tissue perfusion due complete occlusion of the coronary artery by thrombus on top of pre existing atherosclerotic plaque Clinical presentation: Pain usually occurs at rest Indistinguishable from that of angina except that it is more severe , prolonged > 20 minutes and not responding to nitrates Associated signs: pallor, anxious, nausea, vomiting, palpitation, hypotension/hypertension, signs of shock( cold extremities, hypotension , oliguria, cloudiness of consciousness) Investigations As angina pectoris + cardiac specific markers of myocardial damage: After 6 hours: Elevation of troponin I & T Elevation of creatinine phosphokinase (CK-MB) After 12 hours: Elevation of AST/ SGPT After 24 hours: Elevation of Lactic dehydrogenase ( LDH) Complications of myocardial infarction: Arrhythmic ( atrial / ventricular) Heart failure Conduction abnormalities Cardiac rupture Sudden death Pericarditis Post-MI syndrome : fever, chest pain, pleuropericarditis, mostly due to immune mediated mechanism and responds to steroids Thromboembolic manifestations: left ventricular mural thrombus Cardiogenic shock Neurogenic shock Treatment: Nitroglycerine ( vasodilator) Morphine sulphate (pain killer ) Thrombolytic therapy Streptokinase Alteplase Tpa: tissue plasminogen activator Beta blockers: decrease the incidence of fatal arrhythmias & mortality Calcium channel blockers: decrease myocardial oxygen requirements & induces vasodilatation Angiotensin converting enzyme inhibitors( ACEI): prevent cardiac remodelling & decreases mortality Platelet inhibiting agents Aspirin Clopidogrel II a/IIIb: prevent ADP induced platelet aggregation Anticoagulants Treatment of complications : e.g arrhythmia, conduction abnormalities Revascularization: Percutaneous trans luminal coronary angioplasty ( PCI) and stenting Coronary artery bypass graft ( CABG) Heart failure Definition: Inability of the heart to pump blood to meet the oxygen requirements of the tissue needs despite a satisfactory filling pressure. Classification of heart failure: Left sided heart failure versus right sided heart failure Left sided HF: indicates that the failing chamber is the left ventricle Right sided HF: indicates that the failing chamber of the heart is the right ventricle Systolic heart failure versus diastolic heart failure Acute heart versus chronic heart failure Left sided heart failure Etiology of left sided HF: Volume overload: Mitral regurge Aortic regurge Pressure overload Aortic stenosis Systemic hypertension Diseases of the myocardium Myocardial infarction Cardiomyopathy Myocarditis Restrictive heart diseases: Cardiac tamponade ( massive pericardial effusion) Constrictive pericarditis Pathogenesis: Left ventricular failure left ventricular hypertrophy ↑ left ventricular pressure ↑left atrial pressure pulmonary congestion Hallmark of left ventricular failure is pulmonary congestion Inability of the left ventricle to eject blood to the aorta then to different parts of the body ( decreased cardiac output) Symptoms & signs of LHF: Backward manifestations: d.t pulmonary congestion Dyspnea: Subjective feeling of difficulty of breathing Orthopnea: Subjective feeling of difficulty of breathing on lying on the back Paroxysmal nocturnal dyspnoea: Recurrent attacks of difficulty of breathing that occurs at night and awakens the patient from the sleep, typically it occurs from half an hour up to 2 hours after asleep Forward manifestations: d.t decreased cardiac output Angina Syncope: Transient loss of consciousness due to sudden diminution of the blood supply to the brain Dizziness Cold bluish extremities ( peripheral cyanosis) Ischemic bowel disease Ischemic hepatitis Right sided heart failure Etiology of right sided HF: The commonest cause of right sided heart failure is secondary to the left sided heart failure Volume overload: Pulmonary regurge Tricuspid regurge Pressure overload Pulmonary stenosis Pulmonary hypertension Diseases of the myocardium Myocardial infarction Cardiomyopathy Myocarditis Restrictive heart diseases: Cardiac tamponade ( massive pericardial effusion) Constrictive pericarditis Diseases of the lungs( isolated RHF) Chronic obstructive lung diseases(COPD) Primary pulmonary hypertension Pulmonary embolization Pathogenesis: Right ventricular failure right ventricular hypertrophy ↑ right ventricular pressure ↑ right atrial pressure systemic venous congestion Hallmark of right ventricular failure is systemic venous congestion Inability of the right ventricle to eject blood to the pulmonary artery will lead to pulmonary oligemia Symptoms & signs of RHF: Backward manifestations: d.t systemic venous congestion Congested neck veins Tender hepatomegaly ( right upper abdominal pain due to hepatic congestion) Jaundice Anorexia Ascites Lower limb oedema Treatment of HF: Non-pharmacological treatment Treatment of the underlying cause eg hypertension, myocardial infarction, ... Salt restriction in diet Bed rest & avoidance of exercise: only in severe cases of HF Pharmacological therapy Diuretics: A- Beta blocking agents: block the sympathetic over activity, to decrease myocardial oxygen consumption B- Inhibitors of the rennin angiotensin system: it is considered as the corner stone in the treatment of HF as it prevents cardiac remodelling Positive inotropics ( agents to enhance myocardial contractility) Eg. Digoxin ( digitalis) Vasodilators: eg. Nitrates, Hydralazine