2. Definition
Is focal narrowing of coronary arteries as result of intimal
proliferation of smooth muscle cells & the deposition of lipids
Basic lesion is plaque( Atheromatous plaque )
3.
4. Epidemiology
Common cause of cardiovascular morbidity & mortality, more so in western
world
Male: female ratio:
2:1 (all age groups)
8:1 (age<40)
1:1 (age>70)
Disparity due to protective effect of estrogen
Peak incidence of symptomatic IHD is from ages 50 to 60 for men, 60-70 for
women.
Spectrum of IHD ranges anywhere from asymptomatic to sudden death
8. Pathogenesis
The RESPONSE TO INJURY THEORY:
Some injurious stimulus (e.g HTN, Hypercholesterolemia)
cause endothelial damage
Release of growth factors leading to smooth cell
proliferation & migration of macrophages into vessel wall
9. Pathogenesis con’t
The now injured endothelium becomes more permeable, admitting
lipids into the intima
Above changes result into plaque formation, which may
compromise vessel lumen enough to impede blood flow.
If plaque is disrupted, platelets are activated, leading to thrombus
formation & worsening obstruction
10. Pathophysiology: Ischemia
Supply-demand relationship:
Increase in HR & wall stress (e.g with exercise) increases
myocardial oxygen demand.
If demand exceeds supply, ischemia results
Reduced supply: changes in lumen diameter may reduce blood
flow & thus produce ischemia without increase in demand
11. Angina Pectoris
Is chest pain or pressure produced by myocardial ischemia
Precipitated by exertion
It may radiate to: left arm, jaw, teeth, right arm
Symptom complex begins at low intensity, increases over 2-3 min &
lasts < 30 min.
Episodes longer than 30 min imply myocardial infarction
13. Angina Pectoris: Etiology con’t
Increased myocardial oxygen demand:
Myocardial hypertrophy
Severe tachycardia
Severe hypertyroidism
14. Angina Pectoris: Types
• 1: Chronic stable angina: is angina that recurs under similar
circumstances & with similar frequency over time
2: Unstable angina: is a term applied to angina when a change in status
occurs, thus;
- rest angina
- angina of increasing severity, duration or frequency
- new-onset angina
Its more serious clinical condition than chronic stable angina
15. Angina: Diagnosis
History
Classically precordial/ Retrosternal chest pain, tightness or discomfort
radiating to left shlouder/arm/jaw
Predictably precipitated by 3Es: Exercise, Emotion, Eating.
Brief duration < 10-15 min, Relieved by Rest
Note presence of cardiac risk factors (HTN, smoking, DM, Family
history, dyslipidemia)
16. Angina: Diagnosis
• Examination: May be normal in btn attacks, or anxious, ↑PR, ↑BP, S4 or
MR
Investigations
• Resting ECG: Taken in absence of pain is normal in 50% of cases
• Stress testing: Increases sensitivity & specificity of ECG.
• Other stress tests: Scintigraphy, stress radionuclide ventriculography,
Echocardiography,
• Cardiac catheterization with coronary arteriography
Intravascular ultrasound
20. MI: Clinical features
Chest pain
Angina like but more severe ,longer in duration>20 mins,
Not relieved by rest or nitroglycerine
Described as heavy,squeezing,crushing,stabbing
Retrosternal ,Central epigastric,may radiate to arms ,throat
,shoulder, jaw
21. MI: Clinical features
MI without chest pain- post op ,elderly, DM
Isolated dyspnea, exacerbation of HF,or acute confusion may be the presenting features.
Other associated symptomes
Diaphoresis, cold clammy skin, apprehension
Shortnesss of breath, nausea, vomiting, dizziness
Syncope due to bradyarrhythmias
22. MI: Physical signs
Patients appear apprehensive, anxious,cold clammy
Area of chest pain may be indicated by a clenched fist (Levine
sign)
Tachycardia 100-120/min,↑BP due to ↑sympathetic tone (in
>50% pt with ant MI)
Bradycardia <60/min,fall in BP(in2/3 0f inf. MI), hypotension.
23. MI: Physical findings
MR murmur due to papillary muscle infarction.
Crepitations.
Elevated JVP due to heart failure.
Frequently physical signs may be lacking but suspicion of MI
should be high if history is suggestive.
24. MI: Diagnosis
Infarct diagnosis based on 2 of 3:
1. History:
- Sudden onset of characteristic chest pain for > 30 minutes duration
- May be accompanied by symptoms of heart failure
2. ECG Changes
29. MI: Prognosis
20% of patients with acute MI die before reaching hospital
5-15% of those hospitalized will die:
Risk factors for death:
Infarct size (big size, poor prog)
Age (old age poor prognostic factor)
Co-morbidity(DM, Dyslipidemia)
Devt of HF/Hypotension
