Ischemic Heart Disease Diagnosis and Treatment Guide

Ischemic Heart Disease
Professor Dr Md Toufiqur Rahman
31.07.2019
Manikganj
drtoufiq19711@yahoo.com

Professor Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj
.

Case Scenario----1
• A 65 years old hypertensive, smoker, diabetic and
dyslipidemic gentleman from Mymensingh district
presented with central chest tightness on exertion for
last 1 months. His pulse was 104 b/min, BP-150/95
mm Hg, HbA1c-8.2%. His ECG was normal . What
should be his next investigation? What was the
probable cause of his chest tightness?
a. Esophageal spasm
b. Chronic stable angina
c. acute coronary syndrome
d. acute pericarditis

Case Scenario----2
dyslipidemic gentleman from Dhanmondi presented with
central chest tightness with excessive sweating for last 30
minutes not relieved by taking sublingual nitrates. His pulse
was 104 b/min, BP-150/95 mm Hg, HbA1c-8.2%. His ECG
showed ST segment elevation in V1-V5 . What was the
a. Esophageal spasm
c. acute coronary syndrome(STEMI)

Case Scenario----3
dyslipidemic gentleman from Tejgaon presented with
showed ST segment depression in V1-V5 . His Troponin I
level is 30 ng/L. What was the probable cause of his chest
tightness?
a. Esophageal spasm
c. acute coronary syndrome(NSTEMI)

Case Scenario----4
dyslipidemic gentleman from Bashaboo presented with
showed T inversion in V1-V4 . His Troponin I level is
normal. What was the probable cause of his chest
tightness?
a. Esophageal spasm
c. acute coronary syndrome(Unstable angina)

Case Scenario----5
• A 32 years old smoker gentleman from Naogaon
presented with central chest pain for last 5 days with
fever. His pulse was 120 b/min, BP-140/95 mm Hg.
His ECG showed ST segment elevation in lead V1-V6
and lead 2, 3 and aVF . What was the probable cause
of his chest pain ?
a. Esophageal spasm

Case Scenario----6
• A 42 years old smoker gentleman from Rajshahi
presented with central chest pain for last 35 days
increased at night lying flat relieved by taking antacid
syrup. His pulse was 80 b/min, BP-130/85 mm Hg.
His ECG showed normal. What was the probable
cause of his chest pain?
a. Reflux esophagitis

Case Scenario----7
• A 22 years old lady from Khulna district presented
with central chest pain with palpitations for last 5
months. Her pulse was 110 b/min, BP-120/80 mm
Hg. Her ECG showed normal , Echocardiography
showed normal study, ETT done previously for 2 times
were negative. What was the probable cause of his
chest pain?
d. Generalized Anxiety Disorder

Case Scenario----8
• A 25 years old lady from Kustia district presented
with central chest heaviness with palpitations with
low grade fever for last 2 months. Her pulse was
110 b/min, BP-110/70 mm Hg. Her ECG showed low
voltage , Echocardiography showed echo free space
in pericardium. What was the probable cause of his
chest pain?
c. Pericardial Effussion

Case Scenario----9
• A 25 years old lady from Kustia district presented
with central chest heaviness with palpitations with
low grade fever for last 2 months. Her pulse was
110 b/min, BP-110/70 mm Hg. Her ECG showed low
voltage , Echocardiography showed echo free space
in pericardium. What was the probable cause of his
chest pain?
c. Pericardial Effussion

Case Scenario----10
• A 19 years old smoker gentleman from Panchagor
presented with central chest pain for last 5 days with fever
and shortness of breath. His pulse was 120 b/min, BP-
110/75 mm Hg. His ECG showed T inversion in lead V1-
V6 . His echocardiography showed global hypokinesia with
EF-40%, Troponin I positive. What was the probable cause
of his chest pain ?
a. Myocarditis

Case Scenario----11
• A 27 years old gentleman from Chuadanga district
presented with occasional chest pain with
palpitations for last 2 years. His pulse was 110
b/min, BP-110/70 mm Hg. His ECG showed normal ,
Echocardiography showed echo mitral valvular
disease. What was the probable cause of his chest
pain?
a. Mitral valve prolapse
c. Pericardial Effusion

Case Scenario----12
• A 21 years old gentleman from Sathkhira district
presented with occasional central chest pain with
palpitations for last 3 years. He was diagnosed as a
case of Marfans Syndrome. His pulse was 112
b/min, BP-110/70 mm Hg. His ECG showed normal ,
Echocardiography showed echo aortic root dilataion.
What was the probable cause of his chest pain?
a. Mitral valve prolapse
c. Pericardial Effusion
d. Aortic Aneurysm

Case Scenario----13
dyslipidemic gentleman from Jatrabari presented with
severe tearing central chest pain with excessive sweating
for last 30 minutes not relieved by taking sublingual
nitrates. His pulse was 104 b/min, no pulse in lower limbs
BP-150/95 mm Hg, HbA1c-8.2%. His ECG showed left
ventricular hypertrophy . What was the probable cause of
his chest tightness?
a. Esophageal spasm
b. aortic dissection

Case Scenario----14
dyslipidemic gentleman from Jessore presented with
central chest pain with burning sensation in mouth while
taking food. His pulse was 86 b/min, BP-140/95 mm Hg,
HbA1c-8.2%. Oral examination showed oral thrush. His ECG
showed left ventricular hypertrophy . What was the
a. Esophagitis ( Fungal infection)
b. aortic dissection

Terminology
• Angina
• Ischemic Heart Disease
• Coronary artery disease
• Coronary Heart Disease
• Chest pain

• Heart Disease due to ischemia due to any cause
• Coronary artery disease
• Hypertensive heart disease
• Syphilitic heart disease
• Aortic stenosis
• Hypertrophic Cardiomyopathy
• Anaemia
• Aortic dissection

Coronary artery disease
• Any disease involving coronary artery that
may lead to IHD
• Atherosclerosis
• Thrombus
• Embolism
• Inflammation-PAN
• CAD may be Asymptomatic

Coronary Heart Disease
• Heart disease due to coronary artery disease
• IHD

Chest pain
• Chest pain may be cardiac or non cardiac
• May be ischemic or non ischemic(Pericardial
Effusion)
• Ischemia may be coronary or non coronary

Angina/ IHD
• Due to either increased oxygen demand
Or due to reduced oxygen supply
Increased oxygen demand due to hypertrophy of left or
right ventricle
Causes of left ventricular hypertrophy
1. Concentric due to systemic HTN, Aortic stenosis
2. Asymmetrical –cardiomyopathy
Causes of right ventricular hypertrophy
1. Concentric due to pulmonary HTN, Pulmonary
stenosis
2. Asymmetrical – right ventricular cardiomyopathy

Angina/ IHD
• Reduced oxygen supply due to
• Coronary artery obstruction due to
Atherosclerosis, spasm, thrombosis, embolism,
dissection, inflammation
Coronary osteal stenosis due to syphilis
Reduced hemoglobin

Coronary artery disease
presentation
Pathology presentation
Endothelial dysfunction Usually asymptomatic
Occasionally may be chest pain
Minor atherosclerotic plaque(<60%) Usually asymptomatic
Occasionally may be chest pain
Significant Atherosclerotic plaque(>60%-
99%)
Chest pain on exertion(Chronic stable
angina)
Plaque rupture, thrombus, embolism Chest pain in rest(ACS)
100%- ---STEMI
<100%------UA, NSTEMI
No plaque, minor plaque , significant plaque
Prinzmetal angina
Asymptomatic, may be chest pain
occasionally , ACS (prolonged spasm)

Coronary artery disease-Diagnosis
Pathology Investigatins
Endothelial dysfunction ECG-Normal, Echo-Normal, ETT-Negative,
occasionally may be positive, CAG-may be slow
flow, IVUS & OCT-Normal
Minor atherosclerotic plaque(<60%) ECG-Normal, Echo-Normal, ETT-Negative,
occasionally may be positive, CAG-may be slow
flow, minor plaqueIVUS & OCT-Normal
Significant Atherosclerotic plaque(>60%-
99%)
ECG-Normal/ ST-T changes , Echo-
Normal/Hypokinesia, ETT-positive, CAG-may be
slow flow, Significant plaque, IVUS-plaque
burden & OCT-Normal
Plaque rupture, thrombus, embolism ECG- ST-T changes , Echo-Hypokinesia/Akinesia,
ETT- C/I , CAG- no flow, Significant plaque, IVUS-
plaque burden & OCT- thrombus, Trop I-
raised/Normal
Spasm
No plaque, minor plaque , significant
plaque
ECG- Normal/ST-T changes during spasm , Echo-
Normal, ETT- negative , CAG- normal, IVUS-
normal & OCT- normal Trop I- raised/Normaldrtoufiq19711@yahoo.com

Coronary artery disease-Treatment
Pathology Treatment
Endothelial dysfunction Treatment of underlying cause
Anti platelets- slow flow
High dose statin
Minor atherosclerotic plaque(<60%) Treatment of underlying cause/risk factors
Anti platelets ,High dose statin-reduce plaque
burden, plaque stabilization
Significant Atherosclerotic
plaque(>60%-99%)
Treatment of underlying cause/risk factors
burden, plaque stabilization↑ coronary flow-nitrates,
nicorandil ↓after load-nitrates, CCB ↓ work load-BB,
CCB ↓ O2 Utilization at tissue-
Trimetazidine/ranolazine
Plaque rupture, thrombus,
embolism
Treatment of underlying cause/risk factors
burden, plaque stabilization↑ coronary flow-nitrates,
nicorandil ↓after load-nitrates, CCB
↓ work load-BB, CCB . Thrombolytics/ LMWH, O2
Spasm--No plaque, minor plaque , CCB, no BB drtoufiq19711@yahoo.com

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Ischemic Heart Disease Diagnosis and Treatment Guide

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