This document discusses ischemic heart disease and coronary artery disease. It defines stable angina, unstable angina, and myocardial infarction. The causes are an imbalance between oxygen supply and demand to the heart muscle. Risk factors include smoking, hypertension, diabetes, and more. Symptoms may include chest pain and shortness of breath. Diagnosis involves ECG, stress testing, and coronary angiography. Treatment focuses on reducing risk factors, limiting oxygen demand on the heart, and revascularization if needed through procedures like stenting or bypass surgery. The goal is to prevent further heart attacks and reduce cardiac symptoms and mortality.

1. ISCHEMIC HEART DISEASE
Dr Hemant k Jain
Associate Professor
Medicine,GMC Datia

2.  Coronary Artery Disease (CAD): >50% luminal
stenosis of any epicardial coronary arteries.
 CAD manifestations includes
◦ Stable Angina
◦ Acute Coronary Syndrome
◦ Congestive Heart Failure
◦ Sudden Cardiac Death
◦ Silent ischaemia

3.  ACS - USA, MI (NSTEMI, STEMI)
 USA: chest pain + ECG changes without
elevation of cardiac biomarkers
 MI: chest pain + ECG changes with
elevation of cardiac biomarkers

4. Cause
 Imbalance between
◦Myocardial oxygen supply
◦Demand

5. Diagram of the coronary arteries arising from the aorta and encircling
the heart.

6.  Determinants of myocardial oxygen
demand
◦ Heart rate
◦ Myocardial contractility
◦ Myocardial wall tension (stress)
◦ LVH
◦ Valve disease- AS

7. Determinants of myocardial oxygen supply
 Oxygen carrying capacity of blood
◦ Very severe anemia
◦ Corboxy Hb
 Coronary blood flow- luminal stenosis
◦ 50% - inability to ↑ flow to meet ↑ed MVO2
◦ 80%- blood flow at rest reduced
◦ >80%- MI

8.  Total occlusion in the absence of
collaterals for duration of
◦ ≤ 20 min - reversible
◦ >20 min – irreversible

9. Risk Factors
 Smoking
 Hypertension
 Diabetes mellitus
 Obesity
 Dyslipidemia
 Sedentary life style
 Family history of premature CAD
 Age
 Male > 45years
 Female > 55years

10. Clinical features…
 Chest pain
 Breathlessness
 Exercise intolerance
 Fatigue
 Palpitations
 Atypical presentations(heart failure, heart burn, nausea, vomiting,
light-headedness or loss of conciousness )
 Features of Sympathetic over-activity(anxiety,
restlessness, tachycardia, profuse perspiration, peripheral
vasoconstriction, cyanosis)

11. ANGINA
 Stable Angina
 Variant Angina
 Decubitus Angina
 Nocturnal Angina
 Unstable Angina

12. Stable Angina
 Fixed atheromatous stenosis of one or
more coronry arteries
 Typical anginal pain
◦ Retrosternal, tightness or discomfort
◦ Radiating to left(± right) shoulder/arm/
neck/jaw
◦ Brief duration, lasting <10-15 min
◦ Associated with diaphoresis, nausea, anxiety
◦ Worse on exertion
◦ Relieved by rest and nitrates

13. Positive Levine sign-When pt is asked to localize the pain, he/ she typically places a
hand over the sternum, sometimes with a clenched fist, to indicate a squeezing,
central, substernal discomfort

14. Canadian Cardiovascular Society classification
system
Class Definition
CCS
1
Angina with strenuous activity
CCS
2
Angina with moderate activity (walking
greater than two blocks)
CCS
3
Angina with mild activity (walking less
than two blocks)
CCS
4
Angina with any activity or at rest

15. Precipitating factors
 Emotional stress
 Exertion
 Exposure to very hot or cold
temperatures
 Eating ( Heavy meals)
 Smoking

16. Variant Angina (Prinzmetal Angina)
 A spasm in coronary artery
◦ Exposure to cold
◦ Emotional stress
◦ Medicines that tighten or narrow blood vessels
◦ Smoking
◦ Cocaine use
 Occurs at rest
 Not related to exertion
 Small elevations of cardiac enzymes may
occur
 Beta blockers contraindicated
 CCB / nitrate/ other vasodilators are useful

17. 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

18.  Nocturnal Angina
 Angina during sleep (REM)
 Decubitus Angina
 Anginal pain in supine (recumbent) position

19. Physical examination
 Often normal
 Look for evidences of risk factors

20. Investigations
 Biochemical
◦ FBS, PPBS, HbA1c, urine r/m,
◦ Lipid profile
◦ RFT
◦ T3,T4, TSH
◦ CBC
◦ Hs-CRP
◦ CPKMB, Trop T&I

21.  ECG
◦ Often normal
◦ Old MI changes
◦ LVH
 Stress exercise testing
◦ Most useful noninvasive procedure for
evaluation of angina.

22.  Stress testing with imaging
◦ Echocardiographic imaging
◦ Myocardial perfusion imaging
◦ MR perfusion imaging
 Pharmacological stress testing
◦ Dobutamine

23.  Coronary arteriography
◦ Gold standard
◦ Quantify the presence and severity of
atherosclerotic lesions
◦ Assess the non-atherosclerotic causes of
ischemia(eg.-coronary anomaly, aortic
dissection, radiation vasculopathy)

24. TREATMENT

25.  Goals of treatment
◦ To prevent MI
◦ To reduce cardiac death
◦ To reduce symptoms
 Treatment modalities
◦ Medical therapy
◦ Coronary Revasularization
◦ Lifestyle modifications
◦

26.  Improve myocardial oxygen supply
 Reduce MVO2(myocardial volume
oxygen consumption)= SBP*HR
 Control exacerbating factors
 Limit the development of further
atherosclerotic disease

27. Medical therapy
Agents action
Aspirin
clopidogrel
Prevent Pletlets aggregation
and Reduce thrombus
formation
Nitrate Arteriovenous dilation
ACEIs
Beta blockers Reduce MVO2
Ranolazine Noval anti anginal agent
HMG CoA reductase
inhibitors (Statins)
Limit atherosclerotic burden
and reduce cardiac
outcomes

28. Coronary revascularization
 Primary coronary intervention (PCI)
 Coronary Artery Bypass Graft (CABG)
 Indications
◦ Angina refractory to medical therapy
◦ Angina with reduced LV function
◦ Severe activity limiting Angina (CCS class III-IV)
◦ Angina in the presence of LMCA(left main CA) or
severe TVD

29. Cardiac
catheterization
#
vessels
1,2 ≥3
STENT CABG

30. Unstable Angina
 Dynamic obstruction d/t plaque rupture
or erosions with superimposed
thrombosis
 more severe and lasts longer than SA,
may be as long as 30 minutes
 Not relieved by rest or nitrate
 10-20% risk of progression to acute MI

31.  Have a
Good life
With low cardiac risk factors And
Lots of Good days with
lots of exercise capacity