ISCHEMIC HEART

DISEASE
Joana Marie E. Gantuangco

Harrison's Principles of Internal Medicine 19th Edition

Ischemic Heart Disease (IHD)

■ Imbalance between myocardial oxygen supply and demand

■ Most common cause: ATHEROSCLEROTIC DISEASE of an epicardial coronary artery
Pathophysiology

■ O2 Supply < Demand

■ Major determinants of O2 demand:
– Heart rate
– Myocardial contractility
– Myocardial wall tension (stress)
■ Adequate O2 supply requires:
– Satisfactory oxygen-carrying capacity of blood
■ FiO2
■ Pulmonary function
■ Hb concentration and function
– Adequate coronary blood flow
Pathophysiology:
Coronary Blood Flow
■ Phasic fashion: majority during diastole
■ About 75% of total coronary resistance occurs at:
– Large epicardial arteries (R1) – trivial
– Prearteriolar vessels (R2)
– Arteriolar and intramyocardial capillary vessels (R3)
■ Normal coronary circulation is controlled by heart’s O2 demand
■ Coronary vascular bed is able to vary its resistance
■ Goal: myocardium to extract a high and relatively fixed percentage of O2
Pathophysiology:
↓ Supply
■ Most common: atherosclerosis
■ Reduces lumen of coronary arteries  Limits appropriate increase in perfusion
■ Other causes of limited blood flow:
– Prinzmetal’s angina
– Arterial thrombi
– Coronary emboli
– Aortitis
– Congenital anomaly: LADA from PA
■ Reduced O2-carrying capacity of blood (severe anemia)
Pathophysiology:
Coronary Atherosclerosis
■ Major site of atherosclerotic disease: epicardial coronary arteries (branch points)
■ Major risk factors:
– High LDL
– Low HDL
– Cigarette smoking
– Hypertension
– DM
■ ”vulnerable vessel + vulnerable blood  hypercoagulability
■ Develops at irregular rates in different segments  segmental reduction in cross-
sectional area
 50% 80%
(cannot (blood
supply flow at
increased rest is
demand) reduced)
Pathophysiology:
↑ Demand
■ Severe LVH