ISCHEMIC HEART DISEASE

MOHAMED SADAKA, MD
Lecturer of Cardiology & Angiology
Faculty of Medicine- Alexandria University
 Aims and Objectives
 Ischaemic heart disease
 Definition, manifestations, epidemiology, aetiology,
pathophysiology, risk factors and prevention,
 Chest pain
Differential diagnosis
 ACS: UA/NSTEMI
 Acute myocardial infarction
 Assessment, treatment, complications
 Ischaemic heart disease
Definition
 An imbalance between the supply of oxygen and the
myocardial demand resulting in myocardial
ischaemia.

 Angina pectoris
symptom not a disease
chest discomfort associated with abnormal
myocardial function in the absence of myocardial
necrosis
 Ischaemic heart disease
Definition
 Supply
 Atheroma, thrombosis, spasm, embolus
 Demand
 Anaemia, hypertension, high cardiac output (thyrotoxicosis,
myocardial hypertrophy)
 Ischaemic heart disease
Manifestations
 Sudden death
 Myocardial infarction
 Acute coronary syndrome (UA/NSTEMI)
 Stable angina pectoris
 Heart failure
 Arrhythmia
 Asymptomatic (silent ischemia)
 Ischaemic heart disease
Epidemiology
 Commonest cause of death in the Western world. (up
to 35% of total mortality)
 Over 20% males under 60 years have IHD
 Health Survey For England (1993):
3% of adults suffer from angina
1% have had a myocardial infarction in the
past 12 months
Ischaemic heart disease
Aetiology
 Ischaemic heart disease
Aetiology
 Fixed
 Age, Male, +ve family history, female postmenopause
 Modifiable – strong association
 Dyslipidaemia, smoking, diabetes mellitus, obesity,
hypertension
 Modifiable - weak association
 Lack of exercise, high alcohol consumption, type A
personality, OCP, stress

Atherosclerosis
Ischaemic heart disease
Pathophysiology
 Ischaemic heart disease
Pathophysiology
 Response to injury hypothesis
 ATHEROSIS
Accumulation of cholesterol within the vessel wall
intima. Smooth muscle cell proliferation
 SCLEROSIS
Expansion of fibrous tissue
 INFLAMMATION
Chronic inflammatory cells migrate into wall, release
cytokines
 GROWTH FACTORS/INFLAMMATORY
MEDIATORS
 Ischaemic heart disease
Pathophysiology

An atherosclerotic lesion

Schematic illustration

Endothelium Smooth muscle cell

Thrombus formation
Macrophage foam cell
Lymphocytes

Media
(smooth muscle cells)
 Ischaemic heart disease
Acute coronary syndromes
 Fatal AMI
Small, fat rich plaques. Plaque RUPTURE. Thrombus
in lipid core and on plaques surface. Vessel lumen
OCCLUDED.
 Non-fatal AMI
Plaque EROSION rather than rupture. OCCLUSIVE
thrombus.
 Unstable angina
Usually mod-severe stenosis. Multiple vessels. Collaterals
often formed. Thrombus formation and vasoconstriction.
Myocardial infarction may ensue.
 Ischaemic heart disease
Risk factors and prevention
 Ischaemic heart disease
Risk factors and prevention
 Family History
 Smoking
 Hypertension
 Diabetes Mellitus
 Hypercholesterolaemia
 Lack of exercise

 PRIMARY PREVENTION
 Chest Pain
Myocardial ischaemia
 Site
Jaw to navel, retrosternal, epigatic
 Radiation
Left chest, left arm, jaw….mandible, teeth, palate
 Quality/severity
tightness, heaviness, compression…clenched fists
 Chest Pain
Myocardial ischaemia
 Precipitating/relieving factors
physical exertion, cold windy weather, emotion
rest, sublingual nitrates
 Autonomic symptoms

sweating, pallor, peripheral vasoconstriction, nausea and

vomiting
 Angina equivalent:

dyspnea, palpitation, dizziness

 Chest Pain
Differential diagnosis

 Cardiac pathology
 Pericarditis, aortic dissection
 Pulmonary pathology
 Pulmonary embolus, pneumothorax, pneumonia
 Gastrointestinal pathology
 Peptic ulcer disease, reflux, oesophageal spasm,
pancreatitis, ‘café coronary’
 Musculoskeletal pathology
 Trauma, Tietze’s Syndrome
 Acute Myocardial Infarction
 250,000 deaths per year.
 150,000 presentations to hospital.
 30% of deaths occur in the first 2 hours.
(Cardiac muscle death occurs after 45 mins of
ischaemia)
 Acute Myocardial Infarction
Confirming the diagnosis
 Typical chest pain

 Electrocardiographic changes
 ST elevation
 new LBBB
 Myocardial enzyme elevation (early negative)
 Creatine kinase (CK-MB)
 Troponin
 Acute Myocardial Infarction
Treatment
 Rest, sit up and reassure patient
 Oxygen
 Analgesia (opiate, sublingual nitrate)
 Aspirin (300 mg chewable ASA)
 Clopidogrel (300 mg loading dose)
 Adjunctive Therapy

Heparin UPH, LMWH, Fondaparinux

II b /III a inhibitors
Beta blockers
ACE inhibiters or ARBs
Statins
Spironolactone
ASA
Clopidogrel
 Acute Myocardial Infarction
Complications
 Death (18% within 1 hour, 36% within 24 hours)
 Non-fatal arrhythmia
 Acute left ventricular failure
 Cardiogenic shock
 Papillary muscle rupture and mitral regurgitation
 Myocardial rupture and tamponade
 Ventricular aneurysm and thrombus
 Secondary prevention
risk factor modification
 Regular exercise
 LDL less than 70 mg/dl
 BP less than 130/80-120/75
 HGA1c % less than 7
 Stop smoking
 Medication:
 ASA 75-150 mg
 Clopidogrel 75 mg
 BB
 ACEI/ARBs
 Statin
 Spironolactone
THANK YOU