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Ischaemic Heart Disease (IHD), otherwise known as Coronary Artery Disease, is a condition that affects the supply of blood to the heart. The blood vessels are narrowed or blocked due to the deposition of cholesterol plaques on their walls. This reduces the supply of oxygen and nutrients to the heart musculature, which is essential for proper functioning of the heart. This may eventually result in a portion of the heart being suddenly deprived of its blood supply leading to the death of that area of heart tissue, resulting in a heart attack. As the heart is the pump that supplies oxygenated blood to the various vital organs, any defect in the heart immediately affects the supply of oxygen to the vital organs like the brain, kidneys etc. This leads to the death of tissue within these organs and their eventual failure or death. Ischaemic Heart Disease is the most common cause of death in several countries around the world.
Cause and Pathogenesis
A multitude of factors are responsible for the development of IHD. The major risk factors are smoking, diabetes mellitusand cholesterol levels. Those with Hypercholesterolaemia (elevated blood levels of cholesterol) have a much higher tendency to develop the disease. There is also the theory that Hypertension is a risk factor in the development of IHD, Genetic and hereditary factors may also be responsible for the disease. Males are more prone to IHD. However, in postmenopausal women, the risk is almost similar to that of men. Stress is also thought to be a risk factor, though there has been a great deal of debate on this factor of late. The disease process occurs when an atheromatous plaque forms in the coronary vessels, leading to narrowing of the vessel walls and obstructing blood flow to the musculature of the heart. Complete blockage results in deficient oxygenation and nutrient supply to the heart tissues, leading to damage, death and necrosis of the tissue, which is known as Myocardial Infarction (heart attack).
Symptoms and Signs
Quite often, the first sign of Ischaemic Heart Disease may be the severe chest pain of Myocardial Infarction, which may be fatal. However, the warning symptoms occur in a large number of patients in the form of Angina Pectoris. The main symptom of Angina is pain over the central chest that may sometimes radiate down the left arm, to the jaw or to the back. The characteristic feature of the pain is that it is usually aggravated by exercise and relieved by rest, though variant forms may occur. The pain is also relieved by the use of nitrates kept under the tongue. The pain is usually described as a sense of compression or tightness in the middle of the chest, and may last for five to twenty minutes. The pain may be accompanied by sweating. The presence of anginal episodes is virtually diagnostic of IHD.
diet control and life style modification. all of which may indicate a hereditary Hyperlipdaemia. For patients with hypercholesterolaemia. most patients will be able to lead normal and healthy lives. With proper treatment. An exercise testing (Treadmill Test-TMT) is often indicated in patients who have symptoms but have normal ECG patterns. However. obesity. Treatment and Prognosis Drug therapy with Nitrates. which dilate the diseased coronary arteries. may be done to relieve the blockage. thyroid and peripheral vascular disease. Surgical therapy is indicated when medical treatment has failed to relieve symptoms or when the Angiogram shows significant disease in the blood vessels. diabetes.replacing the blocked area of the vessel using a graft from the patient. during the episodes of pain there may be depression of the ST segment and a T wave inversion in several leads. Drugs such as Isosorbide Dinitrate and Isosorbide Mononitrate belong to the category of Nitrates. The patient should also be examined for anaemia.Other signs that can be observed on clinical examination is the presence of Tendon Xanthomas. . avoiding smoking. which may gradually evolve. mainly by decreasing the heart rate. Investigations and Diagnosis Electrocardiography (ECG) may be normal in several patients at rest between attacks of Angina. The indications for bypass surgery are increasingly becoming limited. This is due to the growing realization that except in selected cases. An Echocardiogram may help in showing any functional abnormalities in the various cardiac chambers and in assessing the pumping efficiency of the heart. thickening of the Achilles Tendon and Arcus Lipidus in young patients. TMT is being indicated in all high-risk categories beyond the age of 35 irrespective of symptoms. Coronary Angiogram provides accurate information about the actual site and extent of the stenosis (narrowing) and helps in deciding the method of therapy required. Nowadays. The current trends are to focus on medical treatment and techniques like angioplasty. Beta-blockers like Propranolol are also highly effective in relieving pain by reducing myocardial oxygen demand. drugs may be used to lower cholesterol levels. administered sublingually are very effective in relieving the pain in a few minutes. indicating Ischaemia. Calcium channel antagonists produce vasodilatation and relieve the symptoms by reducing the excitability and conductivity of cardiac muscle and by reducing blood pressure. Good control of diabetesand hypertension significantly improves the outlook. bypass surgery only helps to improve the quality of life and relieve symptoms. In cases of Infarction (heart attack). Treatment also involves advice regarding regular exercise. Myocardial perfusion scanning with radioactive thallium may also be helpful in the diagnosis. These drugs are also used as a prophylactic to prevent the pain from occurring. there will be ST segment elevation in the ECG. Coronary Angioplasty . It does not significantly increase life expectancy.dilating the blocked vessel by inflating a balloon inside the vessel and Coronary Artery Bypass Grafting (CABG) .
As part of an assessment of the three main presentations of IHD. and is more common in men and those who have close relatives with ischaemic heart disease. Ischaemic or ischemic heart disease (IHD). is a disease characterized by ischaemia (reduced blood supply) of the heart muscle. unstable angina or myocardial infarction ("heart attack". and the family history Signs and symptoms Ischaemic heart disease may be present with any of the following problems: Angina pectoris (chest pain on exertion.Prevention Risk factors like a fatty diet. musculoskeletal pain. Its risk increases with age. as they are the main areas of focus in prevention. percutaneous coronary intervention (angioplasty) or coronary artery bypass surgery (CABG). These are the main causes of atherosclerosis (the disease process underlying IHD): age. The medical history distinguishes between various alternative causes for chest pain (such as dyspepsia. diabetes. usually due to coronary artery disease (atherosclerosis of the coronary arteries). smoking. It is the most common cause of death in most Western countries. hypercholesterolaemia (high cholesterol levels). smoking. pulmonary embolism). risk factors are addressed. Diagnosis of IHD is with an electrocardiogram. There is limited evidence for population screening. Diabetes Mellitus and hypertension should be kept under good control with proper treatment. cardiac stress testing or a coronary angiogram. hypertension (high blood pressure). male sex. hyperlipidaemia (high cholesterol and high fats in the blood). sedentary lifestyle and stress should be avoided. and a major cause of hospital admissions. cholesterol and high blood pressure) is used both to prevent IHD and to decrease the risk of complications. or myocardial ischaemia. Depending on the symptoms and risk. or rapidly worsening angina. and hypertension (high blood pressure). in cold weather or emotional situations) Acute chest pain: acute coronary syndrome. but prevention (with a healthy diet and sometimes medication for diabetes. diabetes. Unstable IHD presents itself as chest pain or other symptoms at rest. treatment may be with medication. smoking. Symptoms of stable ischaemic heart disease include angina (characteristic chest pain on exertion) and decreased exercise tolerance. blood tests (cardiac markers). Avoiding foods rich in saturated fats is vital to reduce lipid levels in the blood and to prevent arteriosclerosis. severe chest pain unrelieved by rest associated with evidence of acute heart damage) Heart failure (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle) . Adequate regular exercise is also essential.
If there is no evidence of damage. whichever is available. Myeloperoxidase has been proposed as a biomarker. This process usually necessitates admission to hospital. both for "stable" angina and acute coronary syndrome. The first investigation is an electrocardiogram (ECG/EKG). the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). Depending on the risk assessment. In the absence of ST-segment elevation. echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle).Diagnosis The diagnosis of ischaemic heart disease underlying particular symptoms depends largely on the nature of the symptoms. Acute chest pain Main articles: acute coronary syndrome and myocardial infarction Diagnosis of acute coronary syndrome generally takes place in the emergency department. heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). the term "unstable angina" is used. and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias – irregularities in the heart rate). which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI). stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina. and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication). this is termed a STEMI (ST-elevation MI). Diagnosis is clear-cut if ECGs show elevation of the "ST segment". coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery. Stable angina Main article: angina pectoris In "stable" angina. where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG). If there is evidence of damage (infarction). If part of the heart seems to receive an insufficient blood supply. chest pain with typical features occurring at predictable levels of exertion. An X-ray of the chest and blood tests may be performed. .
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