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ISCHAEMIC HEART DISEASE

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Magnitude of the problem

USA 13.2 Million CAD , angina 6.8 million

CAD 54% of all CVD deaths(2001 US data)

Global deaths,CAD 7.1 to 11.1 million by2020

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A pain, vaguely described as:A heaviness

Pressure

Squeezing sensationConstriction

Aching burning pain

DiscomfortBreathlessness

Fauci et al. Harrison 1998; 1: 59-60.

Angina a typeof temporarychest painpressure ordiscomfort

Narrowedartery

IschemiaHeart muscle is not

receiving enoughoxygen due to anarrowed coronaryartery

DEFINITION

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Typical: Substernal region (center of the chest)Radiation:

Interscapular region(back of the chest)

ArmsShoulders

Teeth

AbdomenBack of neck

SITE

Braunwald et al. Harrison 1998; 1: 1365-80.

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Develops gradually during exertion

Appears after heavy meals

Associated with anger, excitement, frustration and otheremotional states

Resolves within 5-30 minutes

Braunwald et al. Harrison 1998; 1: 1365-80.

TYPICAL ANGINA

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CAD

Stable Angina

Unstable angina

Prinzmetal angina

Acute MI

Silent ischemia

Heart failure

arrhythmia

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STABLE ANGINA

Classification

Exertional

Anginal Equivalent Syndrome

Prinzmetals (Variant) Angina

Syndrome-X

Silent Ischemia

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ACS- clinical presentation

Ebers papyrus 2600BCIf you find a man with

heart discomfort,with pain in arms , at the

side of his heart,death is near

1. Occurring at rest lasting > 20 min

2. New onset severe angina < 1 month3. Crescendo angina

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Unstable angina -classification

Severity

Cl I New onset of severe/crescendo angina, no rest pain

Cl II Angina at rest within in one month but not < 48hrs

Cl III Angina at rest within 48 hrs

Clinical circumstances

A (secondary) extra cardiac condition

B (primary) absence of extra cardiac condition

C (post MI) within 2 weeks of MITIMI III registry , AJC 90:821,2002

Contd

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Unstable angina -classification

Intensity of treatment

1. In the absence of Rx for SAP

2. During Rx of SAP

3. Despite maximal medication for SAP

ECG Changes

With ECG changes

Without ECG changes

TIMI III registry , AJC 90:821,2002

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ACS-patho physiology

1. The development of unstable plaque

2. Acute ischemic event

3. Long term risk of recurrent coronary events

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Non occlusive thrombus

Thrombosis

Platelet activation & aggregation

Secondary haemostasis

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Angina-Dx tests

ECG

Chest X Ray

Resting echo

Exercise echo

Exercise ECG

Stress nuclear scan

Ambulatory ECG

CORONARY ANGIO

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RISK STRATIFICATION

History

Clinical class

ECG

Cardiac markers

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History

Advanced Age > 70 y

Diabetes mellitus

Post MI angina

Prior PAD

Prior CVA

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Angina - physical

Xanthelasma, HTN,PVD

LV dysfunction

Split S2

AS,HOCM, MVP Precipitating factors

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Clinical Presentation

Braunwald Cl II /III ( acute /sub acute)

Braunwald Cl B (sec)

Heart failure / hypotension

Ventricular arrhythmias

ECG changes

ST changes > 0.05 mV

T inversion

LBBB

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Cardiac markers

Increased TROP T /I ,CKMB

Increased CRP or WBC count

Increased BNP

Elevated CD40 ligand

Elevated glucose /HBA1 C Elevated s-creatinine

Angiogram

1. Thrombus

2. Triple vessel disease

3. Reduced LVEF

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Coronary Angio

TACTICS TIMI 18

34% TRIPLE VESSEL DISEASE

28% TWO VESSEL DISEASE

26% ONE VESSEL DISEASE

5-10% LMCD

13% NO CORONARY DISEASE

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Medical therapy

Anti thrombotic Rx

Anti ischemic Rx

Prevention of events

revascularization

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Anti thrombotic Rx

Aspirin

Clopidogrel,ticlopedine Heparin

Direct thrombin inhibitors

Anticoagulants Gp IIb /IIIa inhibitors

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Medical management

1. Identification &treatment of Ppt factors

2. Reduction of coronary risk factors

3. General methods-life style modification

4. Drugs

5. Revascularization- PCI , CABG

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Rx associated diseases

Anemia

Obesity

Occult thyrotoxicosis

Fever

Infection

anxiety

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Coronary risk factors

Hypertension

Smoking

Dyslipidemia

Diabetes

Inflammation- ACEI,Statins

Aspirin, clopidogrel

Beta blockers

Anti oxidents -no role

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Anti anginal drugs- Nitrates

Vasodilator action

Reduce ventricular preload, after load Redistribution of blood flow normal>ischemia

Anti thrombotic effect

Oral, sublingual, transdermal, IV

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Anti anginal drugs- Beta blockers

Anti ischemic, reduce oxygen demand Anti hypertensive

Anti arrhythmic

Reduce mortality in post MI

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Beta blocker

Ideal candidates

1. Physical activity

2. Coexistent HTN3. SVT, vent arrhythmias

4. Old MI

5. LVEF reduced6. Anxiety

Poor candidates

1. Asthma, COPD

2. Severe LVF

3. Severe Depression

4. Raynaud phenomenon

5. PVD

6. Severe bradycardia

7. Brittle diabetes

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Anti angina drugs- CCB

Reduce oxygen demand

Increase oxygen supply

Anti atherogenic

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Other therapies

Nicorndil-IONA study

Spinal cord stimulation

EECP

Chelation- no role

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PCI in angina

Medically refractory pts

Severe myocardial ischemia

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CABG- angina

Medically refractory Angina

LMCD, triple vessel disease

Diabetes with triple vessel disease

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