Ischemic Heart Disease

Year III
2019
 Definition
• Diseases of the heart due to inadequate blood
supply to the heart .
• It is usually due to inadequate supply of blood
to the heart due to problems in the coronary
artery
• It can also be due to increased demand in
normal coronary artery( Increased LV/RV mass
due to LVOT obstruction , Systemic /Pulmonary
Hypertension, etc.).
 Coronary Artery Diseases
• Include
– Atherosclerosis
– Vascuities
– Embolism
– Congenital Malformation
– Vasomotor abnormality
– Mechanical compression/Trauma
– Micro-vascuar Diseases
Coronary Atherosclerotic Disease(CAD)

• Is the most common ischemic heart disease

• Globally CAD is the most common of
death(17.9 million deaths in 2017, 85% heart
attack and ischemic stroke)
• CAD is becoming major cardiovascular disease
in most developing countries especially in
urban areas including Ethiopia.
Epi-cardial Coronary Artery distribution
 Pathogenesis of CAD
A. Risk factors
B. Pathology
 Fatty streak: the earliest lesion
 Atheroma
 Plaque
 Vascular remodelling
C. Clinical Presentation
 Progressive Stenosis : Chronic Stable Angina
 Plaque Rupture : Acute Coronary Syndrome
Pathogenesis of CAD
Plaque Types
Ischemic Cascade
 Diagnosis of Ischemic Heart Disease
• Risk Factors
• ECG
• Cardiac Biomarkers
• Echocardiography
• Coronary CT
• MRI
• Angiography
Clinical Manifestations of Ischemic
Heart Disease
1 . Stable Angina(Angina Pectoris):
Ischemic chest pain appearing due to
inadequate blood supply during exercise due
to fixed stenosis .
Flow is sufficient at rest but is inadequate with
increase demand like during exercise.
 Some patients may not have chest pain but
complain sudden onset SOB or fatigue . These
symptoms are referred to as angina equivalents
 Classification of Chest Pain
1. Classic chest pain(left anterior ,
Squeezing ,crushing , pressure like sensation,
chest tightness , radiates to the arms, doesn’t go
above the jaw or below the umbilicus)
2. Comes with exertion and relieved by rest
3. Relieved by nitroglycerin
Typical Angina: All three of the above are present
Atypical Angina: Two of the three are present
Atypical Chest pain: only one of them are present.
Canadian Classification of Angina
 Diagnosis of Stable Angina
• Clinical : Typical symptoms in those with risk
factors
• Investigations
• Pharmacologic or exercise Stress tests
• Imaging
– Coronary Angiography
– Coronary CT
 Treatment
• Modifications and Treatment of risk factors
• ASA and Statin: For prevention of further CV
events( MI or death)
• Anti-ischemic Treatment (pain management)
– Blockers
– Calcium channel Blocker
– Nitrates
• Percutaneous Coronary Intervention (PCI) for
refractory cases or high risk patients
 2. Acute Coronary Syndromes
• Manifestations are due to plague rupture
with or with out complete occlusion of
coronary artery
• Include
1. Myocardial infarction
2. Unstable Angina
Unstable Angina
Biochemical Changes with myocardial
Ischemia
ECG changes of Ischemia
NSTEMI -ECG
Classification of MI
 Management of ACS
ACS
• Hemodynamic Stabilization
• Reperfusion
• Anti-ischemic Management
• Decrease further event and progression
 I. Hemodynamic Stabilization
• Identify and Treat Life threatening conditions
at spot and CCU.
– Cardiac Arrest
– Significant VT
– Cardiogenic Shock
– Pulmonary Edema
Killip Hemodynamic Classes of MI
 II. Immediate Reperfusion
Should be done at earliest time possible
No benefit after 12 hours unless the patient has
ongoing chest pain or in cardiogenic shock.
Two types of Reperfusion
A. Percutaneous Coronary perfusion(PCI)
More preferable and effective reperfusion strategy.
Indications: -STEMI
-High Risk NSTEMI
 Reperfusion …
B. Thrombolysis
T-PA, streptokinase.
Effectiveness is less after 3hours of onset of
chest pain
Indications : STEMI in set up where PCI is not
possible.
 III. Anti-ischemic Treatment
• B-Blockers ( Metoprolol, bisoprolol and
carvedilol) . Contraindicated in patients with
cardiogenic shock, HR<60/min
• Nitroglycerine
• Pethidine/morphine
• Decrease high demand conditions
– Laxative, bed rest, oxygen for hypoxic conditions,
treat anemia , control BP.
IV . Avoid immediate progression/event

A. Antithrombotic
– ASA : 300 mg chewable then 81-162mg/day for
life
– Clopidegrol 75mg/day
– Heparin for at least five days . Continue warfarin
for those with specific indications.
B. High dose statin
C. ACEI/ARB
 Avoid further event..
E. Risk factor management ( Hypertension, avoid
smoking , alcohol, encourage exercise
D. Implantable Cardioverter and defibrillator
(ICD): with indications( Post cardiac arrest, low
EF )
E. CRT.
 V. Management of Complications
• Aneurism , significant valve lesion and
Rupture: Surgical Treatment may be indicated
• Dressler's syndrome: High dose ASA or
Ibuprofen.
• Heart Failure : Standard Heart failure
Management.
 Long term Treatment
The aim is to avoid future events and decrease mortality
Include:
– ( ASA, Statin, B blockers , ) for all.
– ACEi/ARB, aldosterone antagonist for those with heart failure and
low EF(<40%)
– Anticoagulation for those with LV thrombus, previous stroke and
A.fib
- Risk factor management ( Hypertension, avoid
smoking , alcohol, encourage exercise
- Implantable Cardioverter and defibrillator (ICD)and
CRT: ( Post cardiac arrest, low EF , BBB)