ISCHEMIC HEART DISEASE

Dr. Jalal
IMS/MSU
LEARNING OUTCOME
At the end of this lecture, student should be able to
• Outline the blood supply of the heart

• Explain the pathophysiology of IHD and identify the risk

Factors
• Epidemiology - Malaysia

• Clinical presentations of IHD

• Signs of the Disease

• Investigations

• Immediate Treatment (EM)

• Surgical approach in IHD

• Prevention

• Prognosis
INTRODUCTION

 IHD (CAD)
Inadequate supply of O2 & blood to portion of the myocardium

 The most common form of heart disease

 330 000 people have a myocardial infarct / year

 1.3 million people have angina each year

 90 % due to atherosclerosis

 M>F
The estimated incidence of (ACS) is 141 per
100,000 population per year
CPG 6/2011
Contractility O2 carrying capacity
Heart rate Flow
Myocardial tension
Atherosclerosis
Pathophysiology
Pathophysiology
CA OBSTRUCTION & PRESENTATION
 Asymptomatic

 70-75 % symptomatic at exertion (increase demand)

 90% obstruction = symptoms at rest

 Acute plaque change = ACS

Fissuring – ulceration – Thrombosis
Hemorrhage into core of plaque
REDUCE CA FLOW INCREASE DEMAND
• CA stenosis • Contractility
• Increase pressure • Hypertrophy Emboli
• (Rt atrial / • Rate
• Thyrotoxicosis Arteritis
ventricle)
• Aortic stenosis • Anemia spasm
• Lt ventricular
hypertrophy
RISK FACTORS
Modifiable Risk Factors
• Elevated total and LDL cholesterol
• Low HDL cholesterol
• Elevated BP STRONG
• Diabetes mellitus ASSCIATION
• Cigarette smoking (of any amount)
• Advancing age
• Obesity (BMI>30kg/m2)

Non modifiable : Age / Race / Male / family Hx

Other Precipitating Factors

• Physical inactivity / sedentary
• stress
• Psychosocial factors
CLINICAL PRESENTATION
CLINICAL FEATURES
Symptoms
Central chest pain Criteria?
Dyspnoea
Nausea/vomiting
Sweating
Atypical Presentation

Signs
Pale in MI why?
Sweating
Of underlining risk factors
Of complication
INVESTIGATION
 ECG
 Exercise ECG – ischemic changes
 Stress echocardiography
Exhibit reversible defects in contractility during exercise

 Coronary arteriography
Anatomical information (extent and nature of CAS)

 Cardiac enzymes
 CRP
 CXR
 For Risk factors
ECG & IHD
 Full thickness myocardial infarction - STEMI

A= Normal ECG complex.

B=Acute ST elevation ('the current of injury').
C= Progressive loss of the R wave, developing Q wave
D.resolution of the ST elevation and terminal T wave inversion.
 Anterior non-ST elevation (partial
thickness) infarction – Non STEMI

deep symmetrical T-
wave inversion

Reduction in the
height of the R
wave in leads V1,
V2, V3 and V4.
A= Planar ST depression (myocardial ischaemia)
B= Down-sloping depression (myocardial ischaemia)
C=Up-sloping depression (normal finding)
Exercise ECG
 CARDIAC ENZYMES

The troponin level may not be elevated if the test is done early (<6 hours).
 HIGH TROPONIN

• Myocarditis
• Acute pulmonary embolism
• Dissecting aortic aneurysm
• Heart failure
• Septic shock
• Severe renal dysfunction.
(A raised level is associated with an increase in all cause mortality)
Old infarction
Stress Echocardiography
 Myocardial perfusion scanning

Scintiscans of the myocardium at rest and during

stress

after the administration of an intravenous

radioactive isotope
 Cardiac CT scans

Non-invasive coronary angiography.

Negative predictive value is very high

• CT coronary angiography is particularly useful in

 initial elective assessment of patients with chest pain
 low or intermediate likelihood of disease.
 Coronary Angiography

Occluded Stent implantation

Proximal & patent RCA
RCA
PRINCIPLE OF TREATMENT
Relieve the pain – prevent further cardiac event

Control the risk + precipitating Factors

Angina ACS
Reduce Demand ------
Increase Blood Flow -------

Prevent Platelet
Aggregation

Prevent Thrombosis
TREATMENT OF ANGINA

 Non Invasive
Rest
GTN
Aspirin/ colpidegrol
β. Blockers
Ca+2 Chanel blocking agent
Prinzmetal’s angina
If β. Blockers CI / not tolerated
Avoid precipitating factors

 Invasive
 Percutaneous Coronary Intervention (PCI)
 Coronary artery bypass grafting (CABG)
TREATMENT
PCI
Balloon angioplasty, intracoronary stents)
More effective than medical therapy
Does not reduce mortality.
Procedure-related myocardial infarction
Repeat procedures for re-stenosis.

CABG
Superior to medical treatment (Improve survival)
Greatest benefit occurred
Significant stenosis in the left main coronary artery
Three-vessel disease and impaired ventricular function
Antiplatlet improve graft patency
 PRIMARY ANGIOPLASTY

Severe Proximal Stent Implantation

LAD stenosis & restored LAD flow
CABG VS PCI
TREATMENT OF ACS
• Emergency treatment
Difference in treatment between STEMI & NSTEMI
Where to use thrombolytic agents?
C/I of thrombolytic agent
• Line / IV morphine + antiemetic / O2 high flow mask
• Aspirin/ colpidegrol
• β. Blockers
• CCU admission
• ECG monitoring why?
• Treat complications.
• Surgery in IHD
• Counseling & Rehabilitation
• Prevention
Understanding ACS
 ACS IN BRIEF

Acute Coronary Syndrome

Chest Pain Chest Pain

ST depression / T inversion ST elevation / new onset LBBB

Troponin – ve Troponin +ve Troponin +ve

Unstable Angina NSTEMI STEMI

LMW heparin  glycoprotein IIb/IIIa inhibitor Thrombolysis

Primary PCI