3. 1-Angina
Stable Angina
Unstable Angina
Variant Angina
decubitus angina
nocturnal angina
2-Myocardial infarction
STEMI
NSTEMI
ischemic heart disease (IHD):
is a disease characterized by reduction blood supply of the heart
muscle, usually due to coronary artery disease
ischemic heart disease
4. Epidemiology
• most common cause of cardiovascular morbidity and mortality
• atherosclerosis and thrombosis are the most important
pathogenetic mechanisms.
• peak incidence of symptomatic IHD is age 50-60 (men)
and 60-70 (women)
M>F
7. Angina pectoris
Is a 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
8. Chest pain or discomfort is
usually felt as:
pressure,
heaviness,
tightening,
squeezing,
Chest pain or discomfort
Pain in your arms, neck,
jaw, shoulder or back
accompanying chest pain
Nausea
Fatigue
Shortness of breath
Anxiety
Sweating
Dizziness
Angina symptoms include:
9. 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
10. Emotional stress
Exertion
Exposure to very hot or cold temperatures
Eating ( Heavy meals)
And Smoking
11. Variant Angina
A spasm in a coronary artery
Usually happens when you're resting, unrelated to exercise,
relieved by nitrates
typically occurs between midnight and 8 AM,
The coronary arteries can spasm as a result of:
Exposure to cold
Emotional stress
Medicines that tighten or narrow blood vessels
Smoking
Cocaine use
12. 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
13. 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
14. 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
15. 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
17. Physical examination & signs in angina:
•For most patients with stable angina, physical examination
findings 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 patient's fist
clenched over the sternum when describing the discomfort) is
suggestive of angina pectoris.
18.
19. •Look for physical signs of abnormal lipid metabolism (eg,
xanthelasma, xanthoma) or of diffuse atherosclerosis (eg,
absence or diminished peripheral pulses, increased light
reflexes or arteriovenous nicking upon ophthalmic
examination, carotid bruit).
•Examination of patients during the angina attack may be more
helpful. Useful physical findings include third and/or fourth
heart sounds due to LV systolic and/or diastolic dysfunction
and mitral regurgitation secondary to papillary muscle
dysfunction.
•Pain produced by chest wall pressure is usually of chest wall
origin.
20. Physical examination & signs in unstable angina
and myocardial infarction
Abnormal physical findings are often absent; when present, they are often non-
specific.
An unremarkable physical examination is not uncommon. Perform a quick
assessment 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
21. Unstable angina differs from stable angina in that the discomfort is
usually more intense and easily provoked, and ST-segment depression
or elevation on ECG may occur.
Otherwise, the manifestations of unstable angina are similar to those
of other conditions of myocardial ischemia, such as chronic stable
angina and myocardial infarction.
22. Increased autonomic activity may manifest as diaphoresis or tachycardia, and
bradycardia may result from vagal stimulation from inferior wall myocardial
ischemia.
A large area of myocardial jeopardy may manifest as signs of transient myocardial
dysfunction and typically signifies a higher-risk situation. Signs include the
following:
•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
23. Vital signs and appearance are two of the most important aspects of the physical
exam.
Vital Signs
In the evaluation of a patient presenting with ACS hypotension (systolic blood
pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60
bpm) 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 raise
concern, although they are not specifically suggestive of ACS.
If aortic dissection is considered in the differential diagnosis, blood pressure
should be checked in both arms (>20 mm Hg differential is suggestive of aortic
dissection).
Appearance of the Patient
A patient who appears anxious, diaphoretic, with pale skin and who is in obvious
respiratory distress should demand immediate attention.
24. Eyes
The eye exam is typically not the focus of a physical exam for ACS, however,
details such as pale conjunctiva (suggestive of anemia), exopthalmos (suggestive
of hyperthyroidism), or cotton-wool spots (suggestive of hypertension), or
retinopathy (suggestive of diabetes) on fundoscopic exam should be noted as they
may allow for the identification of potential precipitants of or risk factors for
myocardial ischemia.
Ear Nose and Throat
The 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 patient's
volume 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 above
the right atrium) is considered elevated and reflects elevated right atrial pressure.
25. Heart
The cardiac exam should evaluate for signs of cardiac failure, such as a 3rd heart
sound ("gallop," from early diastolic filling from left ventricular systolic failure), a
4th heart sound ("gallop," from late diastolic filling from a stiff left ventricle, as
from diastolic heart failure) or a new / increased systolic murmur of mitral
regurgitation (as from papillary muscle rupture).
The presence of a pericardial rub would suggest pericarditis instead of ACS.
Lungs
Bibasilar rales are suggestive of congestive heart failure and pulmonary edema.
However, the absence of adventitious lung sounds does not preclude diastolic heart
failure.
Abdomen
The 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 an
aortic aneurysm and requires further urgent evaluation.
26. Extremities
Assess the lower extremities for edema, suggestive of heart failure. It is also
important to palpate the radial, femoral and pedal pulses.
Unequal radial pulses are suggestive of aortic dissection. Weak pedal pulses are
suggestive of peripheral vascular disease. Femoral pulses are important to
document in the event that cardiac catheterization is necessary.
Neurologic
The neurological examination is typically not the focus of a physical exam for
ACS. However, mental status at the time of the initial assessment should be
documented for future reference, should the patient's mental status deteriorate
during 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 hypertensive
emergency as a cause for ACS.
28. 1-ECG
Differential diagnosis of ST segment depression
Myocardial Ischemia
LVH
Severe hypertension
Cardiomyopathy
Anemia
Hypokalemia
Digitalis effect
29. Differential diagnosis of ST segment elevation
Myocardial infarction
Prinzmetal’s angina
Ventricular aneurysm (post MI )
Acute pericarditis
Myocarditis
Hypothermia
30. 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.
31. 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.
32. 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.
33. 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
34. 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.
35. 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
36. 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.
37. Echocardiograph
It reveals 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)
38. 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.
39. 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.
40.
41.
42. 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%.
43. 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
Editor's Notes
An uncoordinated (dyskinetic) apex beat involving a larger area than normal indicates ventricular dysfunction; such as an aneurysm following myocardial infarction
Split during inspiration: normal.[4] (See above)
Split during expiration: Reverse splitting indicates pathology
