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    MED II 1.02c-IHD

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    MED II 1.02c-IHD

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    CRUZ Jill Era
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    12 views15 pages

    MED II 1.02c-IHD

    Uploaded by

    CRUZ Jill Era

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    © All Rights Reserved
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    of 15
    AAscrss" INTERNAL MEDICINE II (15 SEMESTER) IHD | Dr Daet Pree ETT ISCHEMIC HEART DISEASE condition in where there isan inadequte supply of blood and oxygen toa portion of the myocardium «Trozeus wen tere sar bslnce between Inyocoral oxygen supply and demand «Most common caus ATHEROSCLEROTIC DSEASE of an opleardal coronary artery +S Causing auficent reonal rection n myocar loc ow and inadequate paren ck emioesrain TDs the mes common, seis, chon Mo ttveatenng nese > "1a milonpersonshave ND 3 >émion have angio peti 3 Zmnton have sustained myocar intorction Fates suet with the emergence of HD Genetic tacors 5 ight and onergy-teh det 3 srting 3 sedentary testo + Powerfl sk ctor for HO Obesity > tmnt vosstance > Type? labetes malty Cetaltounderstanding the pathophysiology the concept of myocar sappy and demand Sinemet condiions te myocar dum wil contro! the supply of oxygen-rich blood to prevent peutlon of myouyten andthe subsequent development of ischemia and infarction (HARRISONS) « Msjr Determinant of byocardal Oxygen Demand wo) Sear rte > “Myocardial eontactiny > Myocardial wall tension (stress) © Adequate supply of oxygen to the myocardium requlesasostocory veoh «> Onvaencarying capacity ofthe blood + Determined by the mpied ve nyse, pulmonary faon a hemoglobin Concentration and function > Adequate level of coronary blood flow. '* load flows through the coronary arteries in a Phaste Fashion > Majority occurring during systole ‘© 75% of the total coronary resistance to flow occurs in these 3 sets of arteries > Ri (resistance 1) —large epicardial arteries > R2 (resistance 2) — prearteriolar vessels > R3 (resistance 3) ~ arteriolar and intramyocardial capillary vessels ‘# Inthe absence of significant flow limiting atherosclerotic obstructions: > Rlistrivial > Major dotorminant of coronary resistance is found in Rand R3 ‘© Normal coronary circulotion is dominoted and controlled by hearts requirement for oxygen: > Thisis met by the ability of the coronary vessel to vary its resistance > Normally, vessels demonstrate great capacity for dilation (R2 and R3 decrease) ~ example during ‘exercise and emotional stress > Italso adapts to physiologic alterations in blood pressure to maintain coronary blood flow, this i called Autoregulation, MEDI Tohis (15 SEMESTER) IHD | Dr Daet Re _* m - Re Pe © Atherosclerosis, > By reducing the lumen of the coronary arteries, it limits appropriate increase in perfusion when the demand for flow is augments, as occurs during exertion or excitement © Coronary blood flow can also be limited by: > Spasm—example: Prinzmetal Angina > Arterial thrombi > (rarely) coronary emboli > Ostial narrowing due to aorttis > Congenital arteries ‘+ (example) the origin of the LAD coronary artery from the pulmonary arteries may cause Mand infarction in infancy © Sovere Left Ventricular Hypertrophy due to aortic stenosis > Mican occur if the myocardial oxygen demands are markedly increase and particularly when the coronary blood flow may be limited > The aortic stenosis + May present with angina ‘¢ Severe anemia or in the presence of carboxyhemoflobin > Reduction in the oxygen carrying capacity of the blood > Rarely cause MI buy may lower the threshold for ischemia in patients with moderate coronary obstruction cuss! INTERNAL MEDICINE Il Microvascular Angina > Abnormal constriction or failure of normal dilation ‘of the coronary resistance vessels > Can also cause ischemia MEDI Dots AA.cs INTERNAL MEDICINE II a (15 SEMESTER) IHD | Dr Daet PES ‘¢ Epicardial coronary arteries are the major site of atherosclerotic disease @ Major risk factors for atherosclerosis, > High levels of plasma LDL > Low plasma HDL > Cigarette smoking > Hypertension > Diabetes mellitus ‘¢ Irdisturbs the normal functions of the vascular endothelium. Functions include: > Local control of vascular tone > Maintenance of an antithrombotic surface > Control of inflammatory cell adhesion and diapedesis ¢ Loss of thase normal functions/defenses leads to: > Inappropriate constriction > Luminal thrombus formation > Abnormal interactions between blood cells {especially monocytes and platelets and the activated vascular endothelium) ‘© Functional changes result in subintimal collection of: > Fat > Smooth muscle cells > Fibroblasts > Intercellular matrix —defines the atherosclerotic logue © Patients with Diabetes mellitus > They have alterations in the nature of the The combination of this “vulnerable vessels” in 2 patient with “vulnerable blood” promotes a state ‘of hypercoagulability and hypofibrinalytic ‘© edevelops at irregular rates in different segments of the epicardial coronary tree and leads to segmental reduction in cross-sectional area (example: ploque formation) > Branch points in the epicardial arteries Has predilection for atherosclerotic plaques to develop at sites of increase turbulence in coronary flow + When a stenosis reduces the diameter by 50%, there is a limitation of the ability to Ineraace flaw tn meer inrreased myocardial demand + When the diameter is reduced by 80%, blood flow at rest may be reduced, and further ‘minor decreases in the stenotic orifice are ccan reduce coronary flow to cause Ml at fest or with minimal stress © Segmental atherosclerotic narrowing of epicardial coronary artery > Caused most commonly by the formation of a plaque > Which is subject to rupture or erosion of the cap > Upon exposure of the plaque contents to blood. ‘Two processes are set in motion: + Platelets are activated and aggregate +The coagulation cascade is activated leading +0 deposition of fibrin strands MEDI otis AAscrss" INTERNAL MEDICINE II (15 SEMESTER) IHD | Dr Daet > A thrombus composed of platelet aggregates and fibrin strands traps red blood cells and can reduce blood flow, leading to clinical manifestations of MI ‘© Critical Obstruction in vessels > Such as the left main coronary artery and the proximal LAD coronary artery -> HAZARDOUS © Chronic severe coronary narrowing and myocardial ischemia They are accompanied by the development of collateral vessels + When well developed, these vessels can by themselves provide sufi sustain the viability of the myocardium at rest but not during conditions of increased demand + During episodes caused by coronary atherosclerosis: © Myocardial issue oxygen tension falls and may ‘cause transient disturbances ofthe: = Mechanical, *Biochomical. And Electrical functions ofthe myocardium # Coronary atherosclerosis sa focal process that ‘causes NONUNIFORM ISCHEMIA * During ischemia, regional disturbance of ventricular contractility causes © Sogmental hypokinesia © akinesia © Dyskinosia (bulging) —in severe cases Which reduce myocardial pump function Hypokinesia ‘Wall motion abnormality ‘where an area that thickens Jess with systole and doesn’t move quite as well “Akinosia Thinned myocardium thet doesn't move at all ‘Myocardium bulges the wrong way with systole Wall moton abnormaiies vary fom an area hat thickens less with systole and oesi't move gute as wel (hypokinesia) o more obvious abnormal of {tnnnes myocardium that doesnt move a (kinest) nd myocarakm hat geste wrong way st ele (ayexinaet) © Abrupt development of severe ischemia © Occurs with total or subtotal coronary occlusion. © Isassociated with instantaneous failure of normal ‘muscles reloxarion and then contraction vetore angioplasty curing angioplasty MEDI aot Mens! (15 SEMESTER) IHD | Dr Daet INTERNAL MEDICINE II '* Severe Oxygen deprivation Fatty acids cannot be oxidized Glucose is converted to lactate Reduced intracellular pH Reduced ATP and creatine phosphate (high-energy phosphates) ‘+ Severity and duration of the imbalance between ‘myocardial oxygen supply and demand determine whether the damage: © reversible («20 mins for total occlusion in the absence of collaterals) © permanent (220 mins), with subsequent myocardial necrosis ‘= it causes characteristic in the ECG such as repolarization abnormalities: © Inversion of T waves © _ Displacement of ST segments ~ more severe © Transient T-wave inversion reflects: © Non-transmural ischemia © Intramyocardial ischernia ‘© Transient ST-segment depressions reflect: © Patchy subendocardial ischemia = ST-segment elevation © Caused by more severe transmural ischemia Te © Consequences of myocardial ischemia is: © Electrical instability Which leads to isolated ventricular premature beats or NSR With isolated PVC = Ventricular tachycardia oF Ase Harare AST Aca fone ete ST Depression Mat DDIYADI DAI 1 t | Most patient who dies suddenly from IHD do so asa result of © Ischemiainduced ventricular tachyarrhythias MEDI Solis Mens! (15 SEMESTER) IHD | Dr Daet INTERNAL MEDICINE II ‘+ They can olso present with cardiomegaly and heart {foilure secondary to ischemic damages of the lft ventricular myocardium (condition referred to as Ischemic cardiomyopathy) ‘+ Asymptomatic phase of iD may begin before age 20, and during exercise stress test may show evidence of silent myocardial ischemia © Sudden death may be unheralded and isthe common presenting manifestation ‘+ Symptomatic phase of IHD is characterized © Chest discomfort * Due to either angina pectoris or + Acute MI Thiele syrome se to wansient Ml {Mole constiute-70% ofl patients wth angina pectoris andar even pester proportion of those (es than SO your age Women tpi n presentation Astor Typical patent with angina Man 350 year © Woman 260 years + episodes fest discomfort: Vines Sauecting Smothering Choking ‘ Fron pin + Levine igns ono «When asked where the pans, paent pial sas nana Sec Ra aeRO H Crenchod fit onda a squeezing otal, Substernal discomfort © pagina os creat 8 Typialrsts2t05min Radiat to ether shoulder andt both arms {especially the ulnar surfaces of the forearm and " hand) © Canalso radiate to the: = Back | Interscapular region ” = Root of the neck = Jaw = Teeth and = Epigastrium ‘© Rarely localized below the umbilicus or above the mandible 2e Slight © Auseful finding in assessing with patient with chest discomfort is the fact that myocardial ischemic discomfort does not radiate to the Trapezius muscles, typical of pericarditis, © Episodes of angina typically are caused by: = Exertion (exercise, hurrying or sexual activiey) = Emotion (stress, anger, fight or frustration) = Ralioved by rest = Itmay also occur during © Atrest ‘¢ Patient is recumbent (angina decubitus) © Nocturnal angina = May be due to episodic tachycardia Diminished oxygenation as the respiratory pattern changes during sleep, or Expansion of the intrathoracic blood volume that occurs with recumbency © Exertional angina typically is rlieved in 1-5 min by: = slowing or ceasing activities and = even more rapidly by rest = sublingual nitroglycerin EERE oroonscusnnsisecussincaron cater ‘Gau_Fenctons Canton "Sete Feconal Gutenton Greer nh Fae recta ee ‘atro inate Seal hye bryan wen Feet do, eer Sto nasi coc, ivan ocr sae ‘ae mine yokes ort enous Cepuestoaeae TiS omens ‘ional sc Thy we odo eed rg =~ Merked mest ti toca nay hae arya ey Wriocramdeney oct Sear nde he Fyscsy rueor, orton none MEDI Solis AAscrss" INTERNAL MEDICINE II (15 SEMESTER) IHD | Dr Daet © Women and diabetic patients * Angina pectoris may be atypical in location and not strictly related to provoking factors © Angina equivalents These are symptoms of myocardial ischemia other than angina. It includes: Dyspnea Nausea Fatigue And faintnoss = Common in elderly and diabetics (© History establishes the diagnosis of MD until proven otherwise = Fomily history of premature IMD: 0.2 mV Fallin stustolic BP >10mmhG © Development of a V-tach ‘This testis used to discover any limitation in exercise performance, detect typical ECG signs of Ml and establish their relationship to chest discomfort This abnormalities develop during exercise but thery are nat Diagnostic oo 000 © Twwave abnormalities © Conduction disturbances © Ventricular arryhtmias © Negative exerecise tests in which the target ©The Ups heart rate (85% of maximal predicted heart rate for age and sex) is not achieved are considered nondiagnostic > | mm (0.08 sec afer QRS) Very low crear rate smn (0.08 see after QRS) 5% to 10% error rate loping or Junctional ST-segment changes This are not considered characteristic of ischemia and do nat constitute a positive test ‘Types of ST Depression 2 1 mim (0,08 sec after QRS) 30% to 40% error rate “2 Interpretation Sa © False-positive o false-negative result occurs in 4/3 of cases (© Appostive result on exercise indicates that i — the likelihood of CAD is 98% in males who a + >50years, So) [Ree] [ease] [aa + with a history of typical angina echo | | acen | | ecm sean pectoris and + who develop chest discomfort ted Boring the cert ‘+ The ischemic ST-segment response generally is © Thellikelihood decreases ifthe patient has defined as atypical or no chest pain by history and/or ‘© Flar or downsloping depression of the ST during the test segment 20.1 mV below baseline lasting © Incidence of false-positive testis longer than 0.085 significantly increased in patients withlow probabilities of of IHD such as: + Asymptomatic men age <40 Premenopausal women w/no risk factors for premature atherosclerosis ‘Taking cardiocative drugs (digitalis ‘and antlarryhtrmie drugs) MEDI otis Mec BATCH ‘2023 (15 SEMESTER) IHD | Dr Daet = Those with intraventricular conduction disturbances ‘= Resting ST-segment and = Twave abnormalities Ventricular hypertrophy, or = Abnormal serum potassium levels Since the overall sensitivity of exercise stress ECG Is only “7586 a negative result does not exclude CAD although it makes the likelihood of three-vessel or left main Cad extremely unlike A medical professional should be present through the exercise test Lis Important wo measure: = Tota duration of exercise = The times to the onset of ischemic ST-segment change and chest discomfort * The external work performed (expressed as the stage of exercise) = Internal cardiac work performed "Depth of the ST-segment depression and the time needed for recovery of these ECG changes Exercise test can be performed safely in patients as early as 6 days after ‘uncomplicated myocardial infarction Contrainidcations to exercise stress testing include: = Rest angina within 48 hours Unstable rhythm Severe aortie stenosis Acute myocarditis Uncontrolled heart failure Severe pulmonary hypertension = And active infective endocarditis Normal response to graded exercise includes: = Progressive increases in heart rate = Progressive increases Blood Pressure Fallure of the BP to increase or an actual decrease with signs of ischemia during the test isan important adverse prognostic sign "This may reflecy ischemia-induced global left ventricular dysfunction INTERNAL MEDICINE II ‘When the resting ECG is abnormal such as in patients with: © Preexcitiation syndrome (© >1mm of resting ST-segment depression © LBBB © Paced ventricular rhythm Information gained from an exercise test can be ‘enhanced by stress myocardial radionuclide perfusion imaging after IV administration of © Thalium-201 or © 99m-technetium sestamibi A fraction of patients who need noninvasinye stress testing to identify Myocardial ischemia and increased risk of coronary events cannot exercise because of: © Peripheral vascular or musculoskeletal disease © Exertonal dyspnea or © deconditioning ‘MEDI Det Mens! (15 SEMESTER) | IHD | Dr Daet INTERNAL MEDICINE II ‘© inthe patient mentioned above, Intravenous pharmacologic challenge is used in place of exercise. Drugs being utilized are: © dipyrimadole or 2 adenosine = itcreate a coronary “steal” by ‘temporarily increasing flow in nondiseased segments of the coronary vasculature at the expense of diseased segments ‘* ECG is used to assess left ventricular funetion in patients with chronic stable angina and patients with ahistory of: © Prior myocardial infarction © Pathologic Q waves or © Clinical evidence of heart failure ‘* 2.DECG can assess both global and regional wall abnormalities ofthe left ventricle that are transient when due to ischernia ‘= Stress (exercise or dobutamine) echocardiography © May cause the emergence of regions of akinosis or dyskinese that are not present at rest, Stress echocardiography, lke stress myocardial perfusion imaging, is more senstiive than exercise electrocardiography in the diagnosis of IHD E. ELECTRON BEAM (EBCT) and MULTIDETECTOR (MDCT) DETECTION 11-100 Coronary calcium detected by these imaging techniques most commonly is quantified by using, the Agatston score, which is based on the are and density of calcification Diagnostic accuracy of this imaging method is high (© Sensitivity ~ 90-94% © Specificity ~ 95-979 (© Negative predictive value ~ 93-99% © _Its prognostic utility has not been defined ith tow rok of Nondentie| Seen Inne nat Wirral ateroclroi is present. pies Finding re gerastent wilt ork of Bardigvassdar event inthe nok id {thee te or rma coon Stones. Amid risk of Raving CAD en hig calcu score way be High ‘Sareioevtar event wt ‘MEDI Hot Mens! ENS Diagnostic method that outlines the lamina ofthe coronary arteries and can be used to detect or exclude serious coronary obstruction + However it doesn’t provide infermation about the arteril wal, and severe atherosclerosis that does not enroach on the lumen may go undetected + Indications for Coronary arteriography © Patiosnts with chronic stable angina poctore who aro severly symptomatic despite medical therapy and are being considered for revascularization © Patient with troublesome symtoms that present diagnostic aificuties in whom there 2 nocd to confirm or rule out the diagnosis of ID © Pationts with known or possible angina pectoris who have survived cardiac arrest © Patients with angina or evidence of ischemia on noninvasive testing with einical or laboratory evidence of ventricular dysfunction © Patients judged tobe a high risk of sustaining coronary vents based on signs of severe ischomia on noninvasive testing, regardless of the presence or severity of symptoms A. Prognosis; Principal indicators include: + ABe «Functional state of the left ventricles The location and + The severity of coronary arternartowing and the + Severity of myocardial ischemia 8: Indicators for increased risk for adverse coronary vents: ‘ngina pertarie nf recent anset Unstable angina Early postmyocardial infarction angina Angina that's unresponsive or poorly responsive to medical therapy + Angina accompanied by symptoms of congestive heart failure (15 SEMESTER) IHD | Dr Daet © Physical signs of heart failure such as: © Episodes of pulmonary edema © Transient $3 sound © Mitral regurgitation © Echocardiographic = Evidence of cardiac enlargement Reduced (<0.40) ejection fraction . Importatn signs during noninvasive testing indicating a hish risk for coronary events: ‘© Inability to exercise for 6 mins (ex. Stage II Bruce protocol of the exercise test) INTERNAL MEDICINE II * Astrongly positive exercise test showing onset of ‘myocardial ischemia at low workloads (© >0.1 mV ST-segment depression before completion of stage I © 20.2 mV ST-segment depression at any stage © ST-segment depression for 5 min after the cossation of exercise © Deeline in systolic pression >10 mmbg during exercise © Development of V-tach during exercise Development of largo or multiple perfusion defects, Increase lung uptake during stress radioisotope perfusion imaging Decrease in elft ventricular ejection fraction during exercise on radionuclide ventriculography cr during stress echocardiography ERT Most imporatnt signs of left ventricular dysfunction and are associated with poor prognosis © Elevations of left ventricular end diastolic pressure and ventricular volume © Reduced ejection fraction Patients with chest discomfort but normal left ventricular function and normal coronary arteris have an excellent prognosis ‘Obstructive lesions of the left main or left anteriod descending coronary artery proximal to the origin of the first septal artery © 350% luminal diamter © Are associated with greater risk than lesions ‘ofthe right or left circumflex coronary ortery Atherosclerotic plagues in epicardial arteries with {issuirng or filing defects indicate increase risk ‘Mortality is greatly increased when left ventricular function isimpaired Iis essential to collect all the evidence substantiating past myocardial damage, residual left ventricular function and risk of future damage damage from coronory events ‘The greated the number and severity of risk factors, for coronary atherosclerosis the worse the prognosis ‘of an angina patient. Risk factors include: “Advance age 75 yeas old Hypertension Dysipideria Dishes Morbid Obey ‘Accompany peocherl andor CVS dase Provouemyseatdal infarction ‘MEDI Bot AAscrss" INTERNAL MEDICINE II (15 SEMESTER) IHD | Dr Daet Ca (MANAGEMENT OF THE PanieNTWiTH IHD The mangement plan should include the following components: ‘© Explaantion of the problem and reassurance about the ability to formulate a treatment plan ‘© Identification and treatment of aggravating “Any highisk features? conditions Low exercise capacity or ischemia at low workload, large ‘© Recommendations for adaptation of activity area of ischemic myocardum, EF <40%, ACS resentation asneeded ‘© Treatment of risk factors that will decrease the occurrence of adverse coronary outcome (© Drugtherapy for angina ‘ee exrtonal Fe fr coronary © tensideroton of ermnsecton prsoescet werowac ACTIVITIES ss oe ae ‘entinve medical herapy period sess assessment Sool SS (on 2998 Appetcmmng LL LL. LL, FGURER833 Algorithm for management of a patient with ische- Seow ee eg meee Sas" micheart disease. All patients should receive the core elements SSE eT eee of medical therapy as shown atthe top ofthe algorithm. high sk — features ate present. etablbhed by Ue lia hibtay, exerUse ‘data, and imaging studies, the patient should be referred for coronary _artetiography. Based on the number and location ofthe diseased \vessls and their suitability for revasculaization, the patents teated with a percutaneous coronary intervention (PCI or coronary artery bypass graft (CABG) surgary or should be consideted for unconven: tional treatments See text for further discussion. ACS, acute coronary syndrome: ASA, aspitir EF, ejection fraction; IHD, ischemic heart ds- 3s; LM, eft main. En ‘A. Nitrates Systemic venodilation © Reduction in left ventricular end-diastolic volume and pressure ‘© Reducing myocardial wall tension and oxygen requirements Dilation of epicardial coronary vessels Increased blood flow in colalteral vessels ‘MEDI Bet AAscrss" INTERNAL MEDICINE II (15 SEMESTER) IHD | Dr Daet AEICIEEEEEN vorererneraryn mien wir scuemc wea seas ‘© Adverse reaction to beta blockers such as rea PTD depression, sexual disturbance and fatigue Tao + History of asthma or chronic obstructive inert as-2inhes —_“Twoortheetines dy pulmonary disease Tarséemalpach —2.08mgh Bey Mvenoveat + Sicksinus syndrome or significant atrioventricular See conduction disturbances Sibingalnbet —«03.06mg Ase uptote 2 pineal angen seem ee eraere We amelie cre ‘+ Symptomatice peripheral arterial disease tebe ani oal 40m Twoortvetee: iy EE awomansa cn en Oral sustained release 80-120™mg Once or twice dally mere eve ttm sgermen, = Onl noma Twicedhyignen7-h an te Oral sustained release 30-240mg. Once daily, ~ aati saa 110-1012 heathens! ecommerce B. BETA-ADRENERGIC BLOCKERS. Inihibiting the increase in heart rato, arterial prossuro and myocardial contractility oer : «Reduce mortality and reinfarction rates = re as oa a * Moderately effective antihypertensive agents Relative contraindication © Asthma and reversible airway obstruction in D. Antiplatelet Drugs patients with chronic lung disease ASPIRIN © Atrioventricular conduction clsturbances * reves of pale Cox © Severe bradycardia tity seu eaznay ee es Asymptomatic ischemia after myocardial EEE ovens eivouenancs aan infarction, patients with chronic stable = ro a angina and patients with or who have ba i cama survived unstable angina and myocardial : infarction —_ =

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