Ischemia occurs when part of the heart muscle, the myocardium, is deprived of oxygen and

nutrients. Common causes of ischemia are:

 Narrowing or obstruction of a coronary artery.

 A rapid arrhythmia, causing an imbalance in supply and demand for energy.
A short period of ischemia causes reversible effects: The heart cells will be able to recover. When
the episode of ischemia lasts for a longer period of time, heart muscle cells die. This is called
a heart attack or myocardial infarction. That is why it is critical to recognize ischemia on the ECG
in an early stage.
Severe ischemia results in ECG changes within minutes. While the ischemia lasts, several ECG
changes will occur and disappear again. Therefore, it may be difficult to estimate the duration of the
ischemia on the ECG, which is crucial for adequate treatment.
Signs and symptoms of myocardial ischemia:

 Crushing pain on the chest (angina pectoris), behind the sternum, often radiating to the lower
jaw or the left arm
 Fear of dying
 Nausea
 Shock (manifesting as paleness, low blood pressure, fast weak pulse) shock
 Rhythm disturbances (in particular, increasing prevalence of ventricular ectopia, ventricular
tachycardia, AV block)

Risk assessment of Cardiovascular disease

Narrowing of the coronary artery, leading to a myocardial infarction, usually develops over several
years. An increased risk of cardiovascular disease, which may lead to a myocardial infarction or
cerebrovascular accident, can be estimated using SCORE system which is developed by the
European Society of cardiology (ESC). As shown in the figure, the most important risk factors for
myocardial infarction are:

 Male sex
 Smoking
 Hypertension
 Diabetes Mellitus
 Hypercholesterolemia
Risk assessment of ischemia
An exercise test such as a bicycle or treadmill test, may be useful in detecting myocardial ischemia
after exercise.[1] In such a test, continuous ECG monitoring is performed during exercise. The ST-
segment, blood pressure and clinical status of the patient (i.e. chest complaints) are monitored
during and after the test.
An exercise test is positive for myocardial ischemia when the following criteria are met:

 Horizontal or downsloping ST-depression of >1mm, 60 or 80ms after the J-point

 ST elevation of > 1.0 mm