Cardio 3B – Ischemic Heart Disease

ISCHEMIC HEART DISEASE Stress Testing

 test consists of a standardized incremental increase in external workload
ETIOLOGY AND PATHOPHYSIOLOGY while the patient's ECG, symptoms, and arm blood pressure are monitored
 usually symptomlimited chest discomfort, severe shortness of breath,
ISCHEMIA dizziness, fatigue
 refers to a lack of oxygen due to inadequate perfusion, which results from
 ST segment depression of >0.2 mV (2 mm)
an imbalance between oxygen supply and demand
 a fall in systolic blood pressure exceeding 10 mmHg
 most common cause atherosclerosis
 development of a ventricular tachyarrhythmia
 Ischemic ST segment response
CORONARY ATHEROSCLEROSIS o generally defined as flat depression of the ST segment of more than 0.1
Major Risk Factors For Atherosclerosis mV below the baseline (i.e., the PR segment) and lasting longer than
 high plasma lowdensity lipoprotein (LDL) 0.08 s
 low plasma highdensity lipoprotein (HDL)  Upsloping or junctional ST segment changes
 cigarette smoking o not considered characteristic of ischemia and do not constitute a
 hypertension positive test
 diabetes mellitus  false positive or false negative results in 1/3 of cases
 >80% stenosis blood flow at rest may be reduced  Sensitivity of 98% in males over 50 years of age with a history of typical
angina pectoris who develop chest discomfort
EFFECTS OF ISCHEMIA  incidence of false positive tests is significantly increased
 failure of normal muscle contraction and relaxation o in asymptomatic men under the age of 40 or in premenopausal women
 damage is permanent, with subsequent myocardial necrosis (>20 min) with no risk factors
 changes in the electrocardiogram (ECG) o patients taking cardioactive drugs, such as digitalis and quinidine, or in
o repolarization abnormalities those with intraventricular conduction disturbances, resting
o inversion of the T wave abnormalities of the ST segment and T wave, myocardial hypertrophy, or
o ST segment depression reflects subendocardial ischemia abnormal serum potassium levels
o ST segment elevation caused by more severe transmural ischemia  overall sensitivity of exercise stress electrocardiography is only about 75%
 electrical instability may lead to ventricular tachycardia or ventricular  risks of exercise testing are small but real⎯estimated at one fatality and two
fibrillation nonfatal complications per 10,000 tests
 Modified (heart ratelimited rather than symptomlimited) exercise tests
ASYMPTOMATIC VS SYMPTOMATIC IHD o can be performed safely in patients as early as 6 days after myocardial
 approximately 25% of patients who survive acute myocardial infarction infarction
 the same adverse prognosis as those who present with the classic clinical
syndrome Contraindications To Exercise Stress Testing
 ischemic cardiomyopathy  acute myocardial infarction (<45 days)
 sudden death  rest angina <48 hr
 unstable rhythm
STABLE ANGINA PECTORIS  severe aortic stenosis
 acute myocarditis
 chest discomfort
o heaviness, pressure, squeezing, smothering, or choking  Uncontrolled heart failure
 usually crescendo-decrescendo in nature and lasts 1 to 5 min  active infective endocarditis.
 can radiate to the left shoulder and to both arms and especially to the ulnar
surfaces of the forearm and hand.  exercise test can be enhanced by stress myocardial perfusion imaging
 can also arise in or radiate to the back, neck, jaw, teeth, and epigastrium.  Stress (exercise or dobutamine) echocardiography
o may cause the emergence of regions of akinesis or dyskinesis not
 typically caused by exertion or emotion and are relieved by rest
present at rest
 Anginal "equivalents" are symptoms of myocardial ischemia other than
angina
o dyspnea, fatigue, and faintness and are more common in the elderly.

PHYSICAL EXAMINATION
 often normal
 reveals signs of risk factors
 impaired papillary muscle function an apical systolic murmur due to mitral
regurgitation
 can cause transient left ventricular failure
o a third and/or fourth heart sound, a dyskinetic cardiac apex, mitral
regurgitation, and even pulmonary edema.

LABORATORY EXAMINATION
Electrocardiogram
 normal in about half the patients
 repolarization abnormalities at rest (Twave and ST segment changes and
intraventricular conduction disturbances) – nonspecific
o can also occur in pericardial, myocardial, and valvular heart disease or
transiently with anxiety, changes in posture, drugs, or esophageal
disease
 Typical ST segment and T wave changes that accompany episodes of angina
pectoris and disappear thereafter are more specific

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 Cardio 3B – Ischemic Heart Disease
Coronary Arteriography
Outlines the coronary anatomy
 assess the severity of obstructive lesions
 with left ventricular angiocardiography can evaluate both global and
regional function of the left ventricle.
Indications
 patients with chronic stable angina pectoris who are severely symptomatic
despite medical therapy and who are being considered for revascularization
o a percutaneous coronary intervention (PCI)
o coronary artery bypass grafting (CABG)
 patients with troublesome symptoms that present diagnostic difficulties in
whom there is need to confirm or rule out the diagnosis
 patients with known or possible angina pectoris who have survived sudden
cardiac death
 patients judged to be at high risk of sustaining coronary events based on
signs of severe ischemia on noninvasive testing, regardless of the presence
or severity of symptoms
PROGNOSIS
Principal prognostic indicators
 functional state of the left ventricle
 location and severity of coronary artery narrowing
 severity or activity of myocardial ischemia
Indicate a high risk for coronary events
 strongly positive exercise test showing onset of myocardial ischemia at low
workloads [≥0.1 mV ST segment depression before completion of stage II
(Bruce protocol) of the exercise test; ≥0.2 mV ST depression in any stage
 ST depression for > 5 min following the cessation of exercise
 decline in systolic pressure >10 mmHg during exercise
 development of ventricular tachyarrhythmias during exercise
 development of large or multiple perfusion defects or increased lung uptake
during stress radioisotope perfusion imaging
 decrease in left ventricular ejection fraction during exercise on radionuclide
ventriculography or during stress echocardiography.
 most important signs of left ventricular failure on cardiac catheterization
o elevations in LVEDP and ventricular volume
o reduced ejection fraction
 with normal left ventricular function and mild angina but with critical
stenoses (≥70% luminal diameter) of one, two, or three epicardial coronary
arteries,
o 5year mortality rates are approximately 2, 8, and 11%, respectively
 Stenosis (>50% luminal diameter) of the left main coronary artery
o mortality rate of about 15% per year
TREATMENT
Explanation and Reassurance
 understand their condition as best they can
 realize that a long and useful life is possible even though they suffer from
angina pectoris
Identification and Treatment of Aggravating Conditions
 conditions that may either increase oxygen demand or decrease oxygen
supply to the myocardium and may precipitate or exacerbate angina.
Adaptation of Activity
 treadmill exercise test to determine the approximate heart rate at which
ischemic ECG changes or symptoms develop may be helpful in the
development of a specific exercise program.
TREATMENT OF RISK FACTORS
 the treatment of risk factors was developed for the primary prevention of
coronary atheroslerosis, there is growing evidence that it can reduce the
occurrence of angina, myocardial infarction, and death both in subjects
without proven IHD
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Treatment of Dyslipidemia
 men over 45 years and women over 55 years with two risk factors (family
history of premature IHD, cigarette smoking, hypertension, diabetes
mellitus) or evidence of atherosclerotic disease
o Total cholesterol ≤5.17 mmol/L (≤200 mg/dL)
o LDL ≤2.58 mmol/L (≤100 mg/dL)
o LDL ≥1.03 mmol/L (≥40 mg/dL)
 diabetic patients any age need to achieve the same goals as the likelihood
of adverse coronary events is so high
Risk reduction in women with IHD
 incidence of clinical IHD in premenopausal women is very low following the
menopause, the atherogenic risk factors increase (e.g., increased LDL,
reduced HDL) and the rate of clinical coronary events accelerates to the
levels observed in men
DRUG THERAPY
1. Nitrates
 acts by causing systemic venodilation, thereby reducing myocardial wall
tension and oxygen requirements, as well as by dilating the epicardial
coronary vessels and increasing blood flow in collateral vessels
 to minimize the effects of tolerance, the minimum effective dose should be
used and a minimum of 8h each day kept free of the drug so as to restore
any useful response(s).
2. Beta Blockers
 reduce myocardial oxygen demand by inhibiting the increases in heart rate
and myocardial contractility caused by adrenergic activation
 reduce mortality and reinfarction
Relative contraindications to the use of beta blockers
 asthma and revesible airway obstruction in patients with chronic lung
disease
 atrioventricular conduction disturbances
 severe bradycardia
 Raynaud's phenomenon
 a history of depression
Side effects
 fatigue, impotence, cold extremities, intermittent claudication
 bradycardia (sometimes severe), impaired atrioventricular conduction
 left ventricular failure, bronchial asthma,
 intensification of the hypoglycemia produced by oral hypoglycemic agents
and insulin
3. Calcium Antagonists
 are coronary vasodilators that produce variable and dose dependent
reductions in myocardial oxygen demand, contractility, and arterial pressure
 indicated when beta blockers are contraindicated, poorly tolerated, or
ineffective
 Variant (Prinzmetal's) angina
o responds particularly well to calcium antagonists,
 Short acting dihydropyridines
o should be avoided because of the risk of precipitating infarction,
particularly in the absence of beta blockers
indications:
 angina and a history of asthma or chronic obstructive pulmonary disease
 sick-sinus syndrome or significant atrioventricular conduction disturbances
 Prinzmetal's angina
 symptomatic peripheral vascular disease
 adverse reactions to beta blockers⎯depression, sexual disturbances, fatigue
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 Cardio 3B – Ischemic Heart Disease

4. Antiplatelet Drugs
A. Aspirin
 irreversible inhibitor of platelet cyclooxygenase activity
 reduce coronary events in asymptomatic adult men, patients with
asymptomatic ischemia after myocardial infarction, patients with chronic
stable angina, and patients with or who have survived unstable angina and
myocardial infarction.
 side effects such as gastrointestinal bleeding, allergy, or dyspepsia

B. Clopidogrel
 blocks ADP receptor-mediated platelet aggregation

CORONARY REVASCULARIZATION
1. PERCUTANEOUS CORONARY INTERVENTION
Indications and Patient Selection
 angina pectoris, stable or unstable, accompanied by evidence of ischemia in
an exercise test
 more effective than medical therapy for the relief of angina

Risks increase the likelihood of complications

 Advanced age
 stenoses with thrombus
 left ventricular dysfunction
 stenosis of an artery perfusing a large segment of myocardium without
collaterals
 long eccentric or irregular stenoses
 calcified plaques
 overall mortality rate less than 0.5%
 need for emergency coronary surgery less than 1%
 occurrence of clinical myocardial infarction less than 2%

Minor complications: 5 to 10%

 occlusion of a branch of a coronary artery
 myocardial infarction with release of CKMB into the circulation
 complications of arterial catheterization.

Primary success: 95% of cases

Restenosis is more common

 diabetes mellitus
 unstable angina
 incomplete dilation of the stenosis
 dilation of the left anterior descending coronary artery
 stenoses containing thrombi
 totally occlusion
 vein grafts
Successful PCI is less invasive and expensive than CABG, usually requires only 1
to 2 days in the hospital

2. CORONARY ARTERY BYPASS GRAFTING

Mortality increase with
 degree of ventricular dysfunction
 comorbidities
 age above 80 years
 surgical inexperience

Occlusion of vein grafts

 10 to 20% first postoperative year
 2% per year during 5 to 7year followup
 4% per year thereafter

 CABG does not appear to reduce the incidence of myocardial infarction in

patients with chronic IHD
Perioperative myocardial infarction in 5 to 10% of cases, but in most
instances these infarcts are small and have little effect on left ventricular
function.

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 Cardio 3B – Ischemic Heart Disease
Mortality is reduced by operation in patients
 stenosis of the left main coronary artery
 three or two-vessel disease with significant obstruction of the proximal LAD
coronary artery
 bnormal left ventricular function (ejection fraction <50%)
 one or twovessel CAD without significant proximal LAD CAD but with high
risk criteria on noninvasive testing
 obstructive CAD who have survived sudden cardiac death or sustained
ventricular tachycardia
 Previous CABG and who have multiple saphenous vein graft stenoses,
especially of a graft supplying the left anterior descending coronary artery;
 prior PCI recurrent stenosis, and highrisk criteria on non-invasive testing.

All associated with higher perioperative mortality

 CHF and/or left ventricular dysfunction (ejection fraction <40%)
 advanced age (>75 years)
 reoperation
 urgent need for surgery
 presence of diabetes

THE CHOICE BETWEEN PCI AND CABG

PCI and CABG in patients with multivessel CAD
 redevelopment of angina requiring repeat coronary angiography and repeat
revascularization due to restenosis was higher in the PTCA group.
 the occurrence of death or myocardial infarction has been found to be
similar between both groups for up to 5 years
 In patients with diabetes plus disease of two or more coronary arteries,
bypass surgery results in significantly better outcomes and survival and
should be the technique of choice

UNSTABLE ANGINA PECTORIS

 patients with new onset (<2 months) angina that is severe and/or frequent
(≥3 episodes per day)
 patients with accelerating angina
 those with angina at rest

MECHANISMS FOR UNSTABLE ANGINA

 non-occlusive thrombus
o pften a platelet plug⎯overlying a fissured atherosclerotic plaque
 dynamic obstruction
o either spasm of an epicardial coronary artery
 severe, organic luminal narrowing
o as in restenosis following a PCI
 arterial inflammation leading to thrombosis
 increase in myocardial oxygen demands
o caused by conditions such as tachycardia, fever, and thyrotoxicosis in the
presence of fixed, severe coronary obstruction

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 Cardio 3B – Ischemic Heart Disease

PINZMETAL'S VARIANT ANGINA

 characterized by recurrent, prolonged attacks of severe
 ischemia, caused by episodic focal spasm of an epicardial coronary artery
 often are smokers and younger
 pain usually occurs at rest, sometimes awakens the patient from sleep, and
is characterized by multilead STsegment elevation
 diagnosis may be confirmed by detecting transient spasm occurring
spontaneously or following a provocative stimulus (intracoronary
acetylcholine, hyperventilation) on coronary arteriography
 long term survival is excellent
 complications - episodes of disabling pain, myocardial infarction, serious
ventricular arrhythmias, atrioventricular block, and, rarely, sudden death.

TREATMENT
TREATMENT Management may be individualized
 admit to the hospital, placed at rest, sedated, and reassured  the degree of positivity of the stress test, particularly the stage of exercise
 Acute myocardial infarction should be ruled out by means of serial ECGs at which ECG signs of ischemia appear, the magnitude and number of the
and measurements of plasma cardiac enzyme activity perfusion defect(s) on thallium scintigraphy, and the change in left
 IV heparin should be given for 3 to 5 days to maintain the partial ventricular ejection fraction which occurs on radionuclide ventriculography
thromboplastin time at 2 to 2.5 times control aspirin at a dose of 325 mg/d or echocardiography during ischemia and/or during exercise
 Alternatively, low molecular weight heparin  the ECG leads showing a positive response, with changes in the anterior
o e.g., enoxaparin, 1 mg/kg subcutaneously b.i.d. precordial leads indicating a less favorable prognosis than changes in the
 High risk unstable angina patients should also receive an Intravenous inferior leads
infusion of a platelet GpIIb/IIIa inhibitor.  the patient's age, occupation, and general medical condition
o with rest pain
o STsegment deviations and/or release of a marker of myocardial injury  treatment of risk factors, particularly lipid lowering
(such as troponin I or T)  aspirin and beta blockers have been shown to reduce events and improve
 beta blocker outcomes in asymptomatic patients
 calcium antagonist  incidence of asymptomatic ischemia can be reduced by treatment with beta
 Nitroglycerin should be given by the sublingual route as needed for blockers, calcium channel antagonists, and long-acting nitrates
symptoms
 Intravenous nitroglycerin in patients with episodes of ischemia that are
particularly severe or prolonged
 After initial stabilization, either an early invasive strategy (coronary
angiography and revascularization) or early conservative strategy
(continued medical therapy) can be pursued.
 Approximately 80% improve with rest and medical treatment over a 48h
period
 In the early conservative strategy
o Exercise ECG or perfusion scan
o pharmacologic stress test

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