Ischemic heart disease

1. Ischaemic (coronary) heart
disease

2. Introduction
Coronary heart disease is the most
common form of heart disease and the
single most important cause of
premature death in the developed
world.

3. Pathophysiology
Disease of the coronary arteries is
almost always due to atheroma and its
complications, particularly thrombosis.

4. Atheroma
Atheroma or atherosclerosis is a patchy
focal disease of the arterial wall.
Atheromatous plaques begin to appear
in the second and third decade of life.
The nature and composition of these
plaques change as they evolve.

5. Fatty streak develop as circulating
monocyte migrate into intima,take up
oxidised low- density lipoproteins (LDL)
from the plasma, and become lipid
laden foam cells.
In early atheroma, smooth muscle cells
migrate into and proliferate with in the
plaque.

8. A mature fibrolipid plaque has a core of
extracellular lipid surrounded by smooth
muscle cells and is separate from the
lumen by a cap of collagen- rich fibrous
tissue.
Such plaques may rupture, allowing
blood to enter and disrupt the arterial
wall.

9. Risk Factors
Fixed
Age
Male sex
Family history

10. Modifiable
Smoking
Hypertension
Lipid disorders
Diabetes mellitus
Sedentary lifestyle
Obesity
Dietary factors
Lack of physical activity

11. Clinical Features
Shortness of breath
Palpitations
A faster heartbeat
Weakness or dizziness
Nausea
Sweating

12. Myocardial ischaemia

13. Angina pectoris
It is a term used to describe discomfort
due to transient myocardial ischaemia
There is an imbalance between
myocardial oxygen supply and demand
Most common cause------- atheroma,
coronary arterial spasm

14. Angina is worsened by factors
Exercise
Aortic stenosis
Aortic regurgitation
Hypertension
Hyperthyroidism
arrhythmias

15. Clinical features
History is the most important factor in making
diagnosis
STABLE ANGINA ------ typically central
chest pain that is precipitated by exertion and
relieved by rest
UNSTABLE ANGINA----- pain coming on
at rest or minimal exertion
Pain is usually retrosternal in location
Most of patient Describe tightness in the
chest----- like a band round the chest

17. Character of the pain is squeezing,
crushing or aching
Pain commonly radiates to left arm or
less commonly to right arm, throat,
back, chin and epigastrium
Symptoms tend to be worse after a
meal, in the cold, and when walking
uphill or into a strong wind

18. Start-up angina
Nocturnal angina
variant angina ------- (coronary artery
spasm), ST elevation

19. PHYSICAL EXAMINATION
It is frequently negative, but should
include a careful search for evidence of
Important risk factors
Contributory disease
Left ventricular dysfunction
Generalized arterial disease

20. Investigation
ECG; ECG is normal in most of patient at rest
and in between attacks
The most convincing ECG evidence of
myocardial ischaemia is obtained by
demonstrating reversible ST segment
depression or elevation, with or without T
wave inversion
Patient may require exercise testing (treadmill
testing or bicycle ergometry.

21. Myocardial perfusion scanning using
radioactive thallium
Echo cardiography
Coronary arteriography ; provide
information about information about the
extent and site of coronary artery
stenosis

23. Management
General measures
Proper explanation about the disease
Avoid severe unaccustomed exertion, and
vigorous exercise after a heavy meal or in
very cold weather
Stop smoking and reduce weight
Hyperlipidaemia treated with diet and
drugs

24. Drug treatment
Nitrates
Sublingual glyceryl trinitrates
Isosorbide dinitrates
Beta blockers
Propranolol
Calcium channel blockers
Verapamil
nifedipine

25. Surgical treatment
Coronary artery bypass grafting(CABG)
Coronary angioplasty(PTCA)
STENT