Ischemic heart disease occurs when there is inadequate blood flow and oxygen to the myocardium, typically due to blockages in the coronary arteries from atherosclerosis. Risk factors include age, male sex, family history, smoking, hypertension, diabetes, and high cholesterol. Symptoms include chest pain or angina that is usually provoked by exertion and relieved by rest. Diagnosis involves evaluation of symptoms, ECG changes, cardiac stress testing, and coronary angiography. Treatment focuses on lifestyle changes, medications like nitrates and statins, and procedures like angioplasty, stents or bypass surgery to restore blood flow.

1. Ischemic Heart Disease
Logman Mohammed Alshaikh
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2. Ischemic heart disease
• Ischemic heart disease (IHD) is a condition
in which there is anadequate supply of
blood and oxygen to a portion of
myocardium. It tipically occurs when there
is an imbalance between myocardial
oxygen supply and demand.
• The most common cause is atherosclerotic
disease of an epicardial coronary artery.
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3. Etiology
• 1.decresed coronary blood flow by
obstruction(atheroma,spasm,thrombosis,e
mbolus,arteritis,congenital abnormalities)
• 2.increased myocardial oxygen demand
• 3.decresed flow of oxygenated blood to
the myocardium
• 4.cardiac syndrome X(angina in patient
with normal CA (micro vascular angina)
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4. Risk factors
• Fixed
• Age
• Male sex
• Positive family history
• Race
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5. cont
• modifiable
• Hyperlipidaemia
• Cigarette smoking
• Hypertension
• Diabetes mellitus
• Lack of exercise
• Homocysteinaemia

6. cont
• Personality
• Obesity
• Contraceptive pill
• Heavy alcohol consumption
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7. Pathophysiology of myocardial
ischemia
• Myocardial oxigen supply is decreased
– Narrowed coronary arteries (sclerosis, thrombus,
spasmus, coronary embolism, vasculitis)
– Hypotension
– Severe anemia
– Methemoglobinemia, increased carboxyhemoglobin
• Myocardial oxigen demand is increased
– Left ventricle hypertrophy
– Fever
– Hyperthyroidism
– Tachycardy
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8. Coronary atherosclerosis
• Segmental atherosclerotic narrowing of coronary
arteries is caused most commonly by formation of
plaque.
• When a stenosis reduces the diameter of coronary artery
– by 50%, there is a limitation on the ability to
increase flow,to meet increased myocardial
demand
– by 80%, blood flow at rest may be reduced
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9. The clinical manifestations of
ischemic heart disease
• Ischemic heart disease without clinical
symptoms.OR Sudden death can be the
presenting manifestation.
• Cardiomegaly and heart failure that may have
caused no symptoms prior the development of
heart failure – ischemic cardiomyopathy.
• Angina pectoris. Stable angina pectoris.
• Unstable angina/Non ST-elevation myocardial
infarction (NSTEMI)/STEMI = acut coronary
syndromes
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10. Angina pectoris
• Angina pectoris (Latin, angere = press or grip,
pectus = chest) or stenocardia (Greek, stenos =
narrow, cardia = heart) means chest pain
because of episodic myocardial ischemia
• Angina pectoris is the most common
manifestation of the ischemic heart disease.
*Woodwell DA. National ambulatory medical care survey:1998 summary. Adv. Data 2000;19:1-26.
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11. Pathophysiology of
stable/unstable angina &MI
• Stable angina: coronary perfusion
impaired by fixed or stable atheroma of CA
• i-e patient has fixed capacity of exertion
after that he starts feeling chest pain
• Unstable angina :pain on minimal
exertion or at rest . The culiprit lesion is
usually complex ulcerated or fissured
atheroma with adherent PLTT –rich
thrombus and local CA spasm.
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12. cont
• Unstable angina=ulcerated atheroma +
thrombus formation → abrupt reduction of
coronary blood flow caused by thrombus
formation → angina at rest.
• MI: same to unstable angina but there is
total obstruction of coronary artery.
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13. Types of angina Pectoris
• Classical or exertional Angina
Chest pain or discomfort that is
provoked by exertion or emotional
stress and relieved by rest and
nitroglycerin.
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14. Variant (Prinzmetal’s) angina
• Rare, usually occurs at rest—
midnight to early morning hours.
• Pain possibly severe
• Electrocardiogram (ECG) changes
due to coronary artery spasm.
• There is no increased myocardial
demand.
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15. Unstable Angina Pectoris (Pre
infarction)
• Chest pain occurring at rest.
• No increase in oxygen demand is
placed on the heart, but an acute lack
of blood flow to the heart occurs
because of coronary artery spasm or
the presence of an enlarged plaque
or hemorrhage ulceration of a
complicated lesion.
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16. • A change in frequency, duration, and
intensity of stable angina symptoms is
indicative of progression to unstable
angina.
• Unstable angina pain lasts longer than
10 minutes, is unrelieved by rest or
sublingual nitroglycerin, and mimics
signs and symptoms of impending MI.
• Unstable angina can cause sudden
death or result in MI.9/13/2020 logman 16

17. Decubitus angina
• Occurs when patient lies down.its is
usually occurs in assosciation with
impaired left ventricle function
• Patient usually has sever coronary artey
disease
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18. Nocturnal angina
• This is the angina that awakes the patient
sleep.it may be provoked by vivid dreams
• It may be occurs due to critical coronary
artery obstruction or coronary spasm.
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19. Cardiac syndrome X
patient present with angina and positive
ETT (Exercise Tolerance Test), or
ambulatory (Holter) ECG monitoring.and
angiographically normal CA .it may be
due to functional abnormalities of
coronary microcirculation(no dilatation of
arterioles at the time of stress
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20. clinical features if stable angina
• symptoms
• Chest pain
• Dyspnea
• Associated symptoms
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21. 1. Characters of pain
• Sub sternal chest pain, pressure, heaviness,
squeezing, burning, strangling, or cramping
pain.
• a. Pain may be mild or severe and typically
presents with a gradual buildup of discomfort.
• b. May produce numbness or weakness in
arms, wrists, or hands.
• Associated symptoms include
Diaphoresis, nausea, indigestion, dyspnea,
tachycardia, and increase in blood pressure.
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22. 2. Location
behind middle or upper third of
sternum; the patient will make a
fist over the site of the pain
3. Radiation
• Usually radiates to neck, jaw,
shoulders, arms, hands, and
posterior interscapular area.
• Pain occurs more commonly
on the left side than the right.
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23. 4. Duration
Usually lasts 2 to 15 minutes after stopping activity
nitroglycerin relieves pain within 1 minute.
5. precipitating factors
• Exposure to weather extremes
• Eating a heavy meal
• Stress
all increase the workload of the heart, thus
increasing oxygen demand.
• Relieving factors:Rest and nitrate as in stable
angina
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24. Diagnostic Evaluation
• 1. Characteristic chest pain and clinical history.
• 2. Nitroglycerin test—relief of pain with
nitroglycerin.
• 3. Blood tests.
• Hemoglobin to rule out anemia, which may reduce
myocardial oxygen supply.
• HbA1C and fasting lipid panel to rule out modifiable
risk factors for CAD.
• Coagulation studies, CRP (determines inflammation
)
• Cardiac markers, (creatinine kinase CK-MB, and
troponin-I)
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25. ECG
• During pain ST- segment depression with
or without T wave depression that reverse
after ischemia disappears
• ST- segment elevation in prinzmetal
angina
• Resting ECG may be normal between
attacks or may show LVH, ST-T wave
changes, arrhythmias, and Q waves.
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26. ETT (Exercise Tollerance Test)
indications
• To confirm diagnosis of
angina
• To assess prognosis in
CAD pts
• To evaluate response to
therapy
Contra indications
• Acute MI(2days)
• High risk UA
• Decompensated HF
• Arrhythmias
• Acute Myo/pericaditis
• Uncontrolled HTN
• Sever aortic stenosis
• Exercise intolerance
• Severe hypertrophic
cardiomyopathy9/13/2020 logman 26

27. ETT cont
ETT is immediately terminated when there is:
1. Significant chest pain
2. Drop inSBP of >10mmHg of baseline
3. Arrhythmias
4. Severe dyspnea
5. Dizziness,ataxia,fatigue,pallor,or cyanosis
6. ST-depession of >3-4mm
7. ST-segment elevation >1mm
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28. ECG stress testing Ambulatory (Holter) ECG .
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29. • Cardiac catheterization
Coronary angiography performed during the procedure
determines the presence, location, and extent of coronary
lesions.
• Isotpe scanning
• ECHO
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30. Management
Drug Therapy include :
• Nitrates
• Beta -adrenergic blockers
• Calcium channel blockers.
• Asprin
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31. Nitrates
• Action : cause generalized vasodilation
throughout the body.
• Nitrates can be administered orally, sublingually,
trans dermally I.V.
• may provide short- or long-acting effects.
• a. Short-acting nitrates (sublingual) provide
immediate relief of acute anginal attacks
• b. Long-acting nitrates prevent anginal episodes
and/or reduce severity and frequency of attacks.
• s/e ; headache,hypotension,dizzines,tolerance.
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32. • 5. Ant lipid agents—reduce total
cholesterol and triglyceride levels and
have been shown to assist in the
stabilization of plaque.
• 6. Antiplatelet agents—decrease
platelet aggregation to inhibit
thrombus formation. Aspirin are
common used.
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33. Percutaneous Coronary
Interventions
1. Percutaneous trans
luminal angioplasty
• a. A balloon-tipped
catheter is placed in a
coronary vessel narrowed
by plaque.
• b. The balloon is inflated
and deflated to stretch the
vessel wall and flatten the
plaque
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34. 2. Intracoronary atherectomy
• A blade-tipped
catheter is guided into
a coronary vessel to
the site of the plaque.
• Depending on the
type of blade, the
plaque is either cut,
shaved, or pulverized,
and then removed.
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35. 3. Intracoronary stent
A diamond mesh
tubular device is
placed in the coronary
vessel to Prevents
restenosis by
providing a “skeletal”
support.
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36. Other Interventional Strategies
Coronary artery bypass
graft (CABG) surgery
A graft is surgically
attached to the aorta,
and the other end of the
graft is attached to a
distal portion of a
coronary vessel to
returns adequate blood
flow to the heart muscle
supplied by the artery.
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37. Secondary Prevention
• Cessation of smoking
• Control of high blood pressure
• Diet low in saturated fat cholesterol(300
mg/day)
• Low-dose aspirin daily for those at high risk
• Physical exercise .
• Weight control
• Control of diabetes mellitus
• Control of blood lipids
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38. Complications
1. Sudden death due to dysrhythmias
2. Heart failure
3. Myocardial infraction
cont...
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