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ischemic heart diseaseischemic heart disease (IHD): is a disease characterized by reduction blood supply of the heartmuscle, usually due to coronary artery disease 1-Angina 2-Myocardial infarction Stable STEMI Angina Unstable Angina NSTEMI Variant Angina decubitus angina nocturnal angina
Epidemiology• most common cause of cardiovascular morbidity and mortality• atherosclerosis and thrombosis are the most importantpathogenetic mechanisms. • peak incidence of symptomatic IHD is age 50-60 (men) and 60-70 (women)M>F
Etiology 1-Decreased coronary blood flow due to mechanical obstruction such as: Atheroma Spasm of coronary artery Thrombosis Embolism Coronary artreritis 2- Increased myocardial oxygen requirement : Increased cardiac output :thyrotoxicosis Myocardial hypertrophy: aortic stenosis , hypertension 3-Decreased flow of oxygenated blood : anemia
Angina pectoris Isa clinical syndrome characterized by paroxysmal chest pain due to transient myocardial ischemia . It may occur whenever there is imbalance between myocardial oxygen supply and demand the most common cause is atherosclerosis .however angina may also develop in aortic stenosis and hypertrophic cardiomyopathy even there is no coronary atheroma
Angina symptoms include: Chest pain or discomfort Chest pain or discomfort is Pain in your arms, neck, usually felt as: jaw, shoulder or back pressure, accompanying chest pain heaviness, Nausea tightening, Fatigue squeezing, Shortness of breath Anxiety Sweating Dizziness
Stable Angina Atherosclerotic coronary artery disease occurs when the heart has to work harder than normal, during exercise typical: retrosternal chest pain, tightness or discomfort radiating to left(± right) shoulder/arm/ neck/jaw, brief duration, lasting <10-15 min associated with diaphoresis, nausea, anxiety typically relieved by rest and nitrates
precipitatedby the " Es" Emotional stress Exertion Exposure to very hot or cold temperatures Eating ( Heavy meals) And Smoking
Variant AnginaA spasm in a coronary arteryUsually happens when youre resting, unrelated to exercise,relieved by nitratestypically occurs between midnight and 8 AM, The coronary arteries can spasm as a result of:Exposure to coldEmotional stressMedicines that tighten or narrow blood vesselsSmokingCocaine use
SYNDROME X Coronary microvascular disease that affects the heart’s smallest coronary arteries. Typical symptoms of angina but normal angiogram May show definite signs of ischemia with exercise testing
Unstable Angina Due to spasm and partial obstruction of coronaries. Occurs even at rest Is unexpected (new onset) Is usually more severe and lasts longer than stable angina, may be as long as 30 minutes May not disappear with rest or use of angina medication May lead to complete occlusion of vessel causing MI
Myocardial Infarction Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia (total obstruction) Typical symptoms of myocardial infarction include sudden chest pain, shortness of breath, nausea, vomiting, palpitations, sweating weakness, light-headedness Collapse/syncope
Severe pain described as a sensation of tightness, pressure,crushing or squeezing. radiating to left(± right) shoulder/arm/ neck/jaw Chest pain usually lasts for more than 15 minutes Not relieves by rest
Physical examination & signs in angina:•For most patients with stable angina, physical examinationfindings are normal. Diagnosing secondary causes of angina,such as aortic stenosis, is important.•Vital signs especially blood pressure•A positive Levine sign (characterized by the patients fistclenched over the sternum when describing the discomfort) issuggestive of angina pectoris.
•Look for physical signs of abnormal lipid metabolism (eg,xanthelasma, xanthoma) or of diffuse atherosclerosis (eg,absence or diminished peripheral pulses, increased lightreflexes or arteriovenous nicking upon ophthalmicexamination, carotid bruit).•Examination of patients during the angina attack may be morehelpful. Useful physical findings include third and/or fourthheart sounds due to LV systolic and/or diastolic dysfunctionand mitral regurgitation secondary to papillary muscledysfunction.•Pain produced by chest wall pressure is usually of chest wallorigin.
Physical examination & signs in unstable angina and myocardial infarctionAbnormal physical findings are often absent; when present, they are often non-specific. An unremarkable physical examination is not uncommon. Perform a quickassessment of patients vital signs, and perform a cardiac examination.Specific diagnoses that must be explicitly considered are the following:•Aortic dissection•Leaking or ruptured thoracic aneurysm•Pericarditis with tamponade•Pulmonary embolism•Pneumothorax
Unstable angina differs from stable angina in that the discomfort isusually more intense and easily provoked, and ST-segment depressionor elevation on ECG may occur.Otherwise, the manifestations of unstable angina are similar to thoseof other conditions of myocardial ischemia, such as chronic stableangina and myocardial infarction.
Increased autonomic activity may manifest as diaphoresis or tachycardia, andbradycardia may result from vagal stimulation from inferior wall myocardialischemia.A large area of myocardial jeopardy may manifest as signs of transient myocardialdysfunction and typically signifies a higher-risk situation. Signs include thefollowing:•Systolic blood pressure less than 100 mm Hg or overt hypotension•Elevated jugular venous pressure•Dyskinetic apex•Reverse splitting of the second heart sound•Presence of a third or fourth heart sound•New or worsening apical systolic murmur due to papillary muscle dysfunction•Rales or crackles
Vital signs and appearance are two of the most important aspects of the physicalexam.Vital SignsIn the evaluation of a patient presenting with ACS hypotension (systolic bloodpressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60bpm) indicate that a patient is at higher risk.As with the assessment of all patients, other abnormal vital signs such as hypoxia,tachypnea (RR >19), hypothermia (T <95 F) or fever (T >100.3 F) should raiseconcern, although they are not specifically suggestive of ACS.If aortic dissection is considered in the differential diagnosis, blood pressureshould be checked in both arms (>20 mm Hg differential is suggestive of aorticdissection).Appearance of the PatientA patient who appears anxious, diaphoretic, with pale skin and who is in obviousrespiratory distress should demand immediate attention.
EyesThe eye exam is typically not the focus of a physical exam for ACS, however,details such as pale conjunctiva (suggestive of anemia), exopthalmos (suggestiveof hyperthyroidism), or cotton-wool spots (suggestive of hypertension), orretinopathy (suggestive of diabetes) on fundoscopic exam should be noted as theymay allow for the identification of potential precipitants of or risk factors formyocardial ischemia.Ear Nose and ThroatThe ears and nose are typically not the focus of a physical exam for ACS.However, the examination of the buccal mucosa can help to determine a patientsvolume status, as can the examination of the right internal jugular vein pulsations(JVP).A JVP which is elevated greater than 4 cm above the sternal angle (9 cm abovethe right atrium) is considered elevated and reflects elevated right atrial pressure.
HeartThe cardiac exam should evaluate for signs of cardiac failure, such as a 3rd heartsound ("gallop," from early diastolic filling from left ventricular systolic failure), a4th heart sound ("gallop," from late diastolic filling from a stiff left ventricle, asfrom diastolic heart failure) or a new / increased systolic murmur of mitralregurgitation (as from papillary muscle rupture).The presence of a pericardial rub would suggest pericarditis instead of ACS.LungsBibasilar rales are suggestive of congestive heart failure and pulmonary edema.However, the absence of adventitious lung sounds does not preclude diastolic heartfailure.AbdomenThe abdominal exam is typically not the focus of a physical exam for ACS.However, a finding of a expansile, pulsatile mass in the upper abdomen suggests anaortic aneurysm and requires further urgent evaluation.
ExtremitiesAssess the lower extremities for edema, suggestive of heart failure. It is alsoimportant to palpate the radial, femoral and pedal pulses.Unequal radial pulses are suggestive of aortic dissection. Weak pedal pulses aresuggestive of peripheral vascular disease. Femoral pulses are important todocument in the event that cardiac catheterization is necessary.NeurologicThe neurological examination is typically not the focus of a physical exam forACS. However, mental status at the time of the initial assessment should bedocumented for future reference, should the patients mental status deteriorateduring the period of observation.Also, headache in the context of chest pain and severe hypertension (i.e., SBP >210 mm/Hg or a DBP > 120 mm/Hg) would support a diagnosis of hypertensiveemergency as a cause for ACS.
1-ECG Differential diagnosis of ST segment depression Myocardial Ischemia LVH Severe hypertension Cardiomyopathy Anemia Hypokalemia Digitalis effect
Differential diagnosis of ST segment elevation Myocardial infarction Prinzmetal’s angina Ventricular aneurysm (post MI ) Acute pericarditis Myocarditis Hypothermia
2-Exercise Tolerance Test (ETT) This is the most useful noninvasive procedure for evaluation the patient with angina. Ischemia that is not present at rest is detected by precipitation of typical chest pain or ST segment elevation during the exercise using treadmill When history is suggestive of angina pectoris but ECG is normal , then the exercise test should be done.
The test involves recording the 12-lead ECG before , during and after exercise. The test consists of a standardized incremental increase in the external workload while the patient’s ECG, symptoms and the blood pressure are continuously monitored. A variety of exercise protocols are utilized, the most common being the Bruce protocol which increases the treadmill speed and elevation every 3 mins until limited by symptoms.
This test discovers any limitation in exercise performance and establishes the relationship between chest pain and the typical ECG sings of myocardial ischemia. Positive test is one which ST segment is depressed by 1mm(one small square ) More severe disease presents with ST depression more 2 mm at low workload or at heart rate less than 70% of age predicted value, or hypotension develops during exercise.
ETT Report: Degree of ST depression Development of arrhythmia or conduction defect during and post exercise. Duration of exercise. Achievement of age predicted target heart rate ( 220 minus age ) Development of chest pain during exercise. Hemodynamic response
Indications: To confirm the diagnosis of angina To determine the severity of limitation of activity due to angina To asses prognosis in patient with known coronary disease. To evaluate response to therapy.
Contraindications: Acute myocardial infarction ( less 2 days ) High risk unstable angina Decompensated HF Cardiac arrythmias with symptoms Heart block Acute myocarditis and pericarditis Severe aortic stenosis Severe HOCM Uncontrolled HTN
Interpretation: Overall sensitivity of ETT is about 60-75% and specificity 80%. The test may be falsely + or – in 15% of cases therefore negative test does not rule out IHD and positive test without symptoms does not always confirm IHD. If ERR is inconclusive then IHD should be confirmed by thallium scan. ECHO and angiography.
Echocardiograph Itreveals segmental wall motion abnormalities which indicate ischemia or prior infarction. It can be performed at rest while sensitivity increase if performed after exercise or stress given by dobutamine (called dobutamine stress echo)
Isotope scanning Thallium scan and technetium scan shows areas of reduced uptake of radioactive isotope (thallium and technetium) by the myocardium. This test is performed at rest and during stress (produced by exercise or dipyridamol or dobutamine) A perfusion defect present during stress but not all rest indicates reversible myocardial ischemia, whereas a persistent perfusion defect on scan during both phases (rest and stress) usually indicates previous myocardial infarction. Thallium scanning is positive in 75-90% of patients with significant coronary disease. False positive test may occur in women due to breast tissue.
Indication: When ETT is not diagnostic (equivocal or contrary to the clinical impression such as positive test in asymptomatic patient). When patient is unable to perform exercise e.g. patient of unstable angina, aortic stenosis or handicapped patients. In these patients stress is produced by alternatives methods such as drugs e.g. dipyridamol dobutamine or adenosine To distinguish ischemia from myocardial infarction. To localize regions of ischemia. To identify whether the myocardium is viable or not, because revascularization via surgery or angioplasty may be beneficial only for viable myocardium.
Coronary angiograph Coronary angiography visualizes the location and severity of coronary after stenosis. Narrowing greater than 50% of luminal diameter is considered clinically significant, although most lesion producing ischemia are associated with narrowing more than 70%.
Indication: Coronary angiograph is indicated in patient whom coronary revascularization (angioplasty or by-pass) is being considered because of uncontrolled stable angina who have failed to improve on adequate medical regimen To diagnose chest pain of uncertain cause when noninvasive tests have failed to detect the cause. Diagnostic angiography is now rarely performed because diagnosis is usually made on history and non-invasive tests. Unstable angina Post myocardial infarction angina Severe left ventricle dysfunction after MI Non Q-wave MI Strongly positive ETT