IHD PDF - Ischemic Heart Disease

Modified By : Yomna Mohammad A 60 YEAR OLD MALE,SMOKER, DM PRESENTED C/O CHEST PAIN OF 6 MONTHS DURATTION Retrosternal Heavy PPT by exertion Relieved by rest Last about 5 minutes DIAGNOSIS: this is typical presentation of stable angina, which is one common presentation of ischemic heart disease ...

Modified By : Yomna Mohammad A 60 YEAR OLD MALE,SMOKER, DM PRESENTED C/O CHEST PAIN OF 6 MONTHS DURATTION Retrosternal Heavy PPT by exertion Relieved by rest Last about 5 minutes DIAGNOSIS: this is typical presentation of stable angina, which is one common presentation of ischemic heart disease Cardiovascular disease is the leading cause of death worldwide even more than cancer and other diseases Heart Anatomy - The heart is about the size of a fist and weight 300-450 gm - The average beat per minute is 70 (60-100bpm) The average adult heart pumps about 6000-7500 liters of blood per day. (70ccx70x60×24) To keep this muscles pumping the muscles need to have good blood supply The first arterial branch that comes from the aorta is going to go to the heart , the heart is mainly supplied by two coronary systems ; one on the left ( left coronary artery) divided into left anterior descending artery and circumflex artery and one on the right Coronary Circulation physiology Flow during basal cardiac circulation: 70-80 ml/min/100gm (this can increase up to eight times during exercise ) Flow during maximal cardiac work: 300-400ml/min/100gm (to meet this increasement in the blood flow you need to have a good patent coronary arteries , if the coronary artery has a diseased like atherosclerosis for example the patient will suffer from ischemic symptoms due to narrowing artery ) High oxygen extraction: 65%-75% (fixed) ( unlike skeletal muscles the oxygen extraction depends on the state of exercise ) 80% of coronary flow occurs in diastole ( unlike other organs , blood supply the brain during systolic phase) ISCHEMIC HEART DISEASE is a condition where the blood supply to the heart muscle (myocardium) is reduced due to narrowing or blockage of the coronary arteries. 1-Chronic coronary syndrome 2- Acute coronary syndrome This reduction in blood flow leads to an imbalance between oxygen supply and demand, causing symptoms and potential damage to the heart Demand Supply Heart rate We give the patient beta blocker to Coronary flow (patency of coronary artery) Contractility reduce the rate and contractility Hemoglobuline level Wall tension Myocardial oxygen extraction Muscle mass (wall thickness) Arterial oxygen saturation Is a diffused disease that affect any artery in our body , and start in the early childhood resulting from interaction between genetics and environmental factors Risk factors that increase the incidence of atherosclerosis: 1- SMOKING 5- hyperlipidaemia 2- hypertension 6- stressful life styles 3- diabetes 4- Truncal obesity Reversible / treatable Positive family history when the male side less than 55 or the female side less than 65 female 10 years later than males to be affected due to many factors (the most important one is estrogen protection) Start with endothelial dysfunction , this will increase permeability of endothelial to the LDL especially oxides LDL that will accumulate in the subintimal layer with migration of monocytes and macrophages will engulf the lipid and form foam cells that will accumulate together to form atherotic plaque , the plaque will progress with time till it leads to stenosis of the coronary arteries or sometimes rapture of the plaque that leads to acute coronary syndrome or as myocardial infarction If the patient present to us too late What we see is the tip of iceberg Primary prevention very important to prevent the symptoms from development since the most of symptoms need long time to develop Clinical Manifestations of Ischemic Heart Disease 1- Chronic Coronary Syndrome (Angina pectoris, variant angina) chest pain 2- Acute Coronary Syndrome (myocardial infarction, unstable angina) congestive heart failure (CHF) arrhythmias (especially atrial arrhythmia) sudden cardiac death The presentation shows wide spectrum range from asymptomatic to sudden cardiac death  Stable angina Commonest form of angina Causes: imbalance between demand and supply Location: central chest (others) Radiation: arm(s), neck, jaw , toothache( the patient complains from tooth pain (without chest pain ) that is relieved by rest ) Character: squeezing, pressure, heaviness,.. Duration: 2-10 minutes Precipitating factors: exersion, emotional upset, heavy meal, sexual intercoarse, cold weather Relieving factors: nitrate, rest Associated symptoms: dyspnea, diaphoresis, nausea Classes of angina: 1-4 Physical Examination: normal, sign of risk factors, peripheral vascular disease A 60 YEAR OLD MALE,SMOKER, DM PRESENTED C/O TOOTHACHE OF 3 MONTHS DURATION PPT by exertion Relieved by rest Last about 5 minutes DIAGNOSIS: Stable angina As we said, this is a typical site for angina ( neck , teeth , Jaws , trans shoulders , epigastrium , retroscapular ) Diagnosis of Stable angina History: angina pectoris is clinical diagnosis Physical exam Electrocardiogram: 12 ECG, 24 ECG (normal ECG does not rule out any form of ischemic heart disease even infraction can present with normal ECG initially ) Stress ECG: diagnostic and prognostic information Radioactive studies: thalium scan,.. Echocardiography CT Coronary angiography *Serum lipid( LDL, HDL, TG), FBG,CBC Coronary angiography Management goals of stable angina To improve prognosis (mortality reduction) -Modification of risk factors -Aspirin -Lipid-lowering therapy(statins LDL 30 minutes ( site, radiation, severity, character, radiation, associated phenomena, Not respond to sublingual nitrate..) painless MI (10-15%): DM, elderly the patient presented with hypotension, heart failure, arrhythmia, syncope without pain Physical Examination: anxious, stressed, sweaty vital sign: BP, Pulse, Temp auscultation: S4,(S3, Rub The pain also here can develop in the neck , teeth , Jaws , trans shoulders , epigastrium , retroscapular Myocardial infraction diagnosis 1-History 2-ECG (Electrocardiogram): STMI and NSTMI Hyperacute T wave ST-segment elevation: > 2mm in V1-V6, > 1mm in limb leads Q- wave T- inversion ST-segment depresion normal ECG will not exclude MI: Repeat Q 15 min 3-Cardiac Marker: Troponin,CPK, myoglobulin,.. Troponin T,I: 4-6 Hr last 10-14 days СРК:4-6 Hr, peak 17-24hr, normal 72 hr MB(MM,BB) MB2/MB1 >1.5 Treatment of myocardial infraction IN EMERGENCY ROOM: Rapid triage of chest pain (time=muscle) Rapid assessment (Hist and Examination) Establish IV access 12 ECG Aspirin 150-300 mg Orally, clopidogrel 300 mg orally. Oxygen: nasal cannula 2-4 l/min Analgesia: IV morphine, diamorphine 3-5 mg Antiemetic: metoclopromide 10 mg IV Sublingual nitrate: if NO hypotension, RV MI B-blocker: for ongoing chest pain, hypertension, tachycardia GP IIb/Illa inhibitor: if PCI is available (class 2b) ECG monitor Reperfusion: PCI or Thrombolytics PROGNOSIS of MI pre-hospital mortality:20%* hospital mortality:10-12% Poor prognostic featues: Heart Failure EF< 40% Large infarction size Anerior MI New BBB Mobits type 2, and 3rd AV Block Reinfarction or extension of MI Frequent PVC VF or VT Atrial fibrillation Post infarction angina DM Age> 70 female Dentist and IHD patients 1- Avoid Tachycardia ( adrenaline,..) 2- B-blocker should not be stopped abruptly (this will lead to the rebound tachycardia ) 3-Antiplatelet ( type, half life) 4-Anticoagulant