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Dr. Sohail Bashir Sulehria

Assistant Professor (Medicine)

KEMU/ Mayo Hospital Lahore

Ischemic Heart Disease &

its Management

04/21/232/11/2009 2

The coronary arteriesThe coronary arteries..

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1-AnginaStable AnginaUnstable AnginaVariant Anginadecubitus anginanocturnal angina

2-Myocardial infarction

STEMINSTEMI

  

ischemic heart disease (IHD): is a disease characterized by  reduction of blood supply of the heart muscle, usually due to coronary artery disease 

Ischemic Heart Disease 

Epidemiology Epidemiology • most common cause of cardiovascular morbidity and mortality

• atherosclerosis and thrombosis are the most important pathogenetic mechanisms.

• peak incidence of symptomatic IHD is age 50-60 (men)

and 60-70 (women) M>F

EtiologyEtiology 1- Decreased coronary blood flow due to mechanical

obstruction such as: Atheroma Spasm of coronary artery Thrombosis Embolism Coronary artreritis

2- Increased myocardial oxygen requirement : Increased cardiac output :thyrotoxicosis Myocardial hypertrophy: aortic stenosis , hypertension

3- Decreased flow of oxygenated blood : anemia

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Risk FactorsRisk Factors

UncontrollableUncontrollable

•Sex

•Hereditary

•Race

•Age

ControllableControllable

•High blood pressure

•High blood cholesterol

•Smoking

•Physical activity

•Obesity

•Diabetes Mellitus

•Stress and anger

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Angina PectorisAngina Pectoris At least 70% occlusion of coronary artery

resulting in pain. What kind of pain?– Chest pain– Radiating to:

Left shoulder Jaw Left or Right arm

Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies)

Is self limiting usually stops when exertion is ceased

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Angina Pectoris ContinuedAngina Pectoris Continued

Angina Pectoris can be Stable or Unstable:

Stable:– The pain and pattern of events is unchanged

over a period of time (months years)Unstable:

– The pain and pattern is changing, be it in duration, intensity or frequency

– A Myocardial Infarction waiting to happen

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Myocardial InfarctionMyocardial Infarction

Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle

When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels

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Myocardial Infarctions: Myocardial Infarctions: StatisticsStatistics

250,000 deaths per year. 30% mortality within the first 2 hours 45 Minutes of Ischemia:

– Cardiac muscle death occurs How is the Diagnosis Made?

– Electrocardiographic changes ST elevation

– Myocardial enzyme elevation Creatine kinase Troponin C Reactive Protein ECHOETTANGIOGRAPHYTHALIUM SCAN

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Complications ofComplications of M IM I

Infarction leading to inability of the heart to function properly leading to Heart Failure

Angina/PainCardiogenic shock Ventricular aneurysm and ruptureEmbolism FormationArrhythmias Myocardial Infarctions can

lead to Ventricular Fibrillation (shockable!)

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Sudden DeathSudden Death Sudden Death :

– 250,000 deaths in the US per year are caused by what is referred to as “sudden” cardiac death

– Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation

– In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs

– V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”

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Many people are able to manage coronary artery disease with lifestyle changes and medications.

Other people with severe coronary artery disease may need angioplasty or surgery.

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Management of Ischemic Management of Ischemic Heart Disease:Heart Disease:

Lifestyle:– Diet– Exercise Preventive treatment• Low fat, low cholesterol diet• Cessation of smoking• Red wine (in moderation)

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Management of Ischemic Management of Ischemic Heart DiseaseHeart Disease::

Pharmacological Agents:– Beta Blockers

Act either selectively or non-selectively on Beta receptors:– Beta 1 cardiac muscle increase rate and contraction– Beta 2 dilates bronchial smooth muscle

– Ca++ Channel Blockers Acts on vasculature blocking Ca++ and causing vasodilation

– Nitrates Vasculature vasodilation

– Anti-Hypercholesterolemia HMG CoA Reductase Inhibitors reduction in “manmade”

cholesterol thus helping to reduce atheroma formation– Antiplatelet Medication:

Clopidogrel (Plavix) Aspirin

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Surgical TreatmentSurgical Treatment

1) Stenting

2) Angioplasty (balloon)

3) Bypass surgery

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Thank You