Diagnosing Ischemic

Heart Disease
Marc Kenneth F. Cabanero
1st year FM Resident UST
Reference:
Objectives:
General Objective:
• To improve the quality of health care among Filipinos with CAD
Specific Objectives:
• To assist Filipino physicians in making clinical decisions in the management of coronary
artery disease.
• To define the standard of care for coronary artery disease in the local setting.
• To make existing international guideline more clinically relevant and applicable to local
practice.
Introduction:
• The global and local burden of ischemic heart disease is significant. In the Philippines,
cardiovascular disease ranked among the top 10 leading causes of morbidity and was the
leading cause of mortality in 2009.
• In the local setting, chest pain was the most common symptom in patients with ACS
occurring in 74% while anginal equivalents presented only in 25%
• CAD may present as one or more of three clinical presentations: SIHD, NSTE-ACS,
and STEMI
• SIHD- stable presentation of CAD
• ACS is where patients experience active ischemic discomfort even at rest and may have 2
presentations:
• ACS with ST-Elevation
• NSTE-ACS (ACS with Non ST-Elevation)- Differentiated by the level of Cardiac Enzyme.
• Unstable Angina (UA)
• Non ST-Elevation MI
Stable Ischemic Heart Disease
• Statement 1: History is STRONGLY RECOMMENDED as the most essential part of the
initial evaluation and includes detailed description of the symptom of chest pain,
classification of the severity of chest pain, and determination of presence of risk factors
and co-morbid conditions.
• Careful history remains the cornerstone of diagnosis of stable angina.
• Characteristics of chest pain related to myocardial ischemia include 5 components:
quality or character; location; duration; precipitating factors; relieving factors.
Ischemic Heart Disease
CCS Classification of Angina Severity
Ischemic Heart Disease

• Statement 2: A focused physical examination is STRONGLY RECOMMENDED during

initial evaluation to exclude other conditions associated w/ angina, search for evidence of
non-coronary vascular disease and identify signs of co-morbid conditions.
• A focused PE may exclude other conditions associated w/ angina such as: anemia,
hypertension, valvular heart disease, hypertrophic obstructive cardiomyopathy or
arrhythmias.
Ischemic Heart Disease
• Statement 3: A resting 12L ECG is RECOMMENDED during initial evaluation, and
during or immediately after an episode of chest pain suspected to indicate clinical
instability
• Statement 4: RECOMMENDED that the ff. lab tests be performed to establish CV risk
factors, identify possible causes of ischemia and determine prognosis: Fasting Lipid
Profile, Fasting Glucose and/or HBA1c, or OGTT (if both are inconclusive), CBC, Crea
w/ EGFR, Trop T or I, Thyroid function test (Clinical suspicion of thyroid disorder),
Liver Function test (after beginning statins)
• Statement 5: CXR (PA and Lat views): RECOMMENDED in pts. w/ s/sx of CHF,
aortic dissection and aneurysm; valvular heart disease; pericardial disease or pulmonary
disease.
Ischemic Heart Disease
• Statement 6: 2D Echo w/ Doppler IS RECOMMENDED in the initial evaluation of all
patients for exclusion of alternative causes of angina; identification of segmental or
regional wall motion abnormalities suggestive of CAD; measurement of LVEF, LV
diastolic function for risk stratification purpose.
• Statement 7: Ambulatory 24hr ECG monitoring is RECOMMENDED in patients w/
suspected arrhythmia.
Pre-Test Probability (PTP) Assessment for SIHD
• Assessment determine whether or not to proceed w/ further non-invasive or invasive
testing to establish diagnosis of SIHD.
Pre-Test Probability Assessment of SIDH
Establishing Diagnosis
• Prinicples of Stress Testing: Non-invasive stress testing IS STRONGLY
RECOMMENDED in patients w/ intermediate Pre-Test Probability (PTP)
Assessment in order to establish the diagnosis and risk stratification of patients
• The incremental information provided by such testing will influence clinical decision-
making on subsequent management.
• The generally higher sensitivity of a stress imaging study (70%-90%) compared to
exercise ECG or Treadmill exercise test (45%-50%) is the reason why a stress imaging
study is the preferred test modality.
Stress Test Imaging

• Stress imaging study IS RECOMMENDED as initial diagnostic and prognostic test if

facilities, resources and local expertise permit in patients within the higher range of PTP.
• Patients w/ LVEF less than 50% w/o typical angina
• Patient w/ resting ECG abnormalities and especially symptomatic patient w/ prior
revascularization (PCI) or CABG.
Stress Echocardiography, Stress MPI and Stress CMR

• Stress Echocardiograpy – performed w/ exercise treadmill or bicycle ergometer.

• Stress MPI – Using chemical either thallium 201 or technetium 99 as radiopharmaceutical
tracers in association w/ either symptom limited exercise on a treadmill or bicycle
ergometer or pharcological stress testing w/ adenosine/dobutamine.
• Stress CMR – uses technology such as magnetic and radiofrequency fields. Similar to
stress echocardiograpy, it can detect wall motion abnormalities induced by ischemia from
a dobutamine infusion.
Stress Echocardiography, Stress MPI and Stress CMR
Exercise ECG (Treadmill Exercise Test)

• RECOMMENDED as the initial diagnostic and prognostic test, if resources and local
expertise for a stress imaging study are not available, in patients w/ intermediate PTP who
have normal resting ECGs and are able to exercise.
Invasive Coronary Angiography

• RECOMMENDED in patients w/ high PTP either as initial test or after an initial non-
invasive study w/ stress imaging or Treadmill Exercise Test.
• NOT RECOMMENDED in patients who REFUSE invasive procedures and prefer
medical therapy, and those in whom revascularization is not expected to improve
functional status or quality of life.
Diagnosing Non ST-Elevation ACS
• CVD remains to be the number one cause of mortality and a substantial contributor to
morbidity in the Philippines.
• From November 2011 to November 2013, the mortality rate for ACS was 7.8%
• ACS is further classified as ST-Elevated ACS and NSTE-ACS.
• The elevation of cardiac enzymes further distinguishes NSTE-ACS into NSTEMI and
Unstable Angina (UA).
Clinical Presentation
It is RECOMMENDED that patients w/ ff. s/sx undergo immediate assessment for the
diagnosis of ACS:
1. Chest pain or severe epigastric pain, non-traumatic in origin. W/ typical MI component:
Central or substernal compression or crushing chest pain pressure, tightness,
heaviness, cramping, burning, aching sensation.
2. Unexplained indigestion, belching, epigastric pain.
3. Radiating pain in neck, jaw, shoulders, back, or one or both arms
4. Unexplained syncope
Clinical Presentation
5. Palpitations
6. Dyspnea
7. Nausea or vomiting
8. Diaphoresis
• Traditional clinical presentation of ACS: prolonged anginal pain (> 20mins) at rest, new-
onset severe angina, crescendo or accelerated angina.
• Atypical symptoms are more common in elderly, women, diabetics, or patients with
chronic kidney disease.
• The primary goal of PE is to exclude non-ischemic causes and non-cardiac causes of the
clinical presentation.
Electrocardiogram
• It is STRONGLY RECOMMENDED that a 12L ECG be obtained immediately within
10 minutes of ER presentation in patients w/ ongoing chest discomfort.
• If initial ECG is not diagnostic but w/ symptoms highly suspected for ACS a serial ECG
at 15 to 30 minutes intervals should be performed to detect potential development of ST
segment elevation or depression.
• Patients who present w/ ST-segment depression are initially considered to have UA or
NSTEMI.
Biomarkers

• It is RECOMMENDED that QUANTITATIVE troponin be measured in all patients w/

chest discomfort consistent w/ ACS. In patients w/ initially negative cardiac markers, a
repeat determination within 3 hours of presentation increases the sensitivity for MI
diagnosis to almost 100%
• High sensitivity troponin I or T are the preferred markers for myocardial injury. They are
more specific and more sensitive than CKMB
• Troponins are elevated in NSTEMI but are within normal levels in UA.
Non-Invasive Imaging

• RECOMMENDED that an echocardiogram be done in all patients suspected to have

ACS for evaluation of global and regional LV function, for ruling in or out differential
diagnoses and for prognostic information.
• MAY BE RECOMMENDED to perform coronary computerized tomography
angiography (CTA) to exclude ACS in those w/ non-diagnostic ECG and Troponin, and
have a low to intermediate likelihood of CAD.
Stress Testing

• NOT RECOMMENDED to perform in patients with active chest pain

• MAY BE RECOMMENDED in those with non diagnostic ECG and normal cardiac
biomarkers with no active chest pain for more than 12 hours. My be done pre-discharge
or as OPD basis.
Diagnosing ST-Elevation Myocardial Infarction
• IT IS STRONGLY RECOMMENDED that patients w/ possible STEMI symptoms such
as chest discomfort, SOB, diaphoresis, nausea, sudden weakness or syncope should be
immediately brought to ER.
• Morbidity and mortality from STEMI can be reduced by early recognition of symptoms
and timely medical consultation and treatment.
• Patients and relatives should be given information on how to recognize s/sx of STEMI
and should be informed of the urgency of seeking medical attention.
Initial Evaluation at ER
• It is STRONGLY RECOMMENDED that a targeted history taking, PE, and 12L-
ECG should be taken within 10 minutes of arrival at the ER.
• The objective of initial evaluation is for physician to rapidly and reliably diagnose
STEMI and determine the patients eligibility for reperfusion therapy.
• TARGETED HISTORY and PE taken in the ER should be DETAILED ENOUGH to
establish probability of STEMI but should be OBTAINED RAPIDLY so as not to delay
reperfusion therapy.
• If STEMI is present after ECG, a decision whether the patient will be treated w/
fibrinolytic therapy or PCI should be made.
ECG Evaluation
• It is STRONGLY RECOMMENDED that patients presenting w/ chest discomfort and
ECG finding of at least 0.1mV ST segment elevation in 2 contiguous leads should receive
reperfusion therapy (PCI or thrombolytics) if not contraindicated.
• It is RECOMMENDED to observe for ECG tracings that make dx of acute myocardial
infarction (AMI) difficult: LBBB, ventricular paced rhythm, non-diagnostic ST segment
elevation w/ persistent ischemic symptoms, isolated posterior MI, ST elevation in lead
aVR. Presence of marked ST elevation and Hyperacute T-waves require reperfusion
therapy.
Laboratory Evaluation
• It is RECOMMENDED that laboratory examination should be performed as part of the
management of STEMI patients but should not delay the implementation of reperfusion
therapy.