myocardial ischemia presentation

1. Myocardial Ischemia
Presented by
Priyanka Priyadrsani Nayak

2. Myocardial Ischemia
• Myocardial ischemia occurs when the blood
flow demands of the heart exceed the blood
supplied by the coronary arteries.
• The leading cause of myocardial
ischemia is:
a) atherosclerosis or
b) Coronary thrombosis.

3. pathophysiology of myocardial
ischemia:
Under conditions of rest, myocardial oxygen supply and
delivery of nutrients through the coronary arteries should
match the metabolic requirements of the heart. When the
metabolic needs of the heart increase, the coronary blood
flow must increase accordingly.
The myocardial oxygen balance is affected by several factors
that :
a) will increase the oxygen and nutrient demand of the
myocardium as: exercise, stress and cold.
b) will increase coronary blood flow as cardiac metabolites and
nitric oxide.

4.  With age and progressive occlusion of coronary arteries, smaller
collateral vessels may begin to carry a greater proportion of
blood and provide an alternate means of perfusion for an area
of myocardium. These collateral blood vessels may run parallel
to the larger coronary arteries and be connected to other small
coronary vessels by vascular connections called anastomoses.
 Development of collateral circulation may reduce or delay the
occurrence of symptoms from myocardial ischemia until the
blockage is very progressed.
 The presence of extensively developed collateral circulation
might also explain why many older individuals often survive
serious heart attacks when younger individuals, who have not
yet developed collateral circulation, often do not.

5. Manifestation of myocardial
ischemia:
• Angina pectoris
 It is the major symptom of myocardial ischemia.
 Angina pectoris most commonly presents as severe
pain the chest.
There are three types of Angina pectoris
1. Classic or stable angina
Pain is precipitated by increased workload on the heart. May be
caused by exercise, emotions, stress and cold exposure.
Symptoms may remain “stable” for a number of years or progress in
severity.

6. 2. Unstable angina
Angina that occurs at rest.
Also referred to as “pre-infarct” angina since it is usually
associated with extensive blockage of coronary arteries. Coronary
blood flow does not meet the needs of the heart even at rest.
Requires intensive treatment and evaluation.
3. Variant angina (vasospastic angina, Prinzmetal’s angina)
Caused by vasospasm of the coronary arteries.
Usually associated with coronary artery disease but may result
from excess sympathetic activity.
Frequently occurs at night, at rest or during minimal exercise.
May be precipitated by stress, cold exposure or smoking.

7. Silent ischemia
is a particularly dangerous form
of myocardial ischemia as there
is a lack of clinical symptoms,
i.e., ischemia without angina.
Usually diagnosed by exercise
stress testing or Holter
monitoring.

8. Diagnosis of myocardial ischemia:
1. Electrocardiograph
2. Holter monitoring — 24 ambulatory electrocardiograph
3. Stress testing with electrocardiograph
4. Nuclear imaging
5. Cardiac catheterization

9. Rationale for treatment of myocardial
ischemia:
• Treatment of myocardial ischemia
and the resulting angina can
involve two strategies:
• 1. Increase coronary blood flow by
dilating coronary arteries.
• 2. Reduce cardiac workload by
reducing heart rate and/or force of
contraction

10. The treatment regimen may include :
1. nonpharmacologic treatment
2. pharmacologic therapies.
Nonpharmacologic treatment
Pacing of physical activity.
• Avoidance of stress (emotional, physiologic, cold).
• Reduction of risk factors for ischemic heart disease,
(hyperlipidemia, obesity, hypertension, diabetes,
smoking, etc.)

11. Pharmacologic treatment
Organic Nitrates
Mechanism of action:
• Dilate coronary arteries and increase myocardial blood flow.
• Dilate peripheral arteries and reduce afterload.
• Dilate peripheral veins and reduce preload.
Examples
Amyl nitrate, nitroglycerine, isosorbide dinitrite
Route of administration : Inhalation, sublingual, oral, transdermal, intravenous
Long-acting forms such as isosorbide dinitrite used for prophylaxis of angina
Short-acting forms such as sublingual nitroglycerin may be used during angina
attacks
Major adverse effects :include headache, hypotension. Tolerance may develop
rapidly.

12. β-Adrenergic blockers
Mechanism of action:
Block myocardial β-adrenergic receptors.
Reduce heart rate and cardiac output (reduced
myocardial workload and oxygen demand).
Examples of β-Adrenergic Receptor Antagonists :
May be selective β1 (atenolol), or
nonselective β1 and β2 blockers (propranolol)
Major adverse effects :
include bradycardia, reduced cardiac output,
pacemaker
depression and bronchoconstriction with
nonspecific drugs

13. Calcium channel blockers
• Mechanism of action:
• Block calcium channels in vascular smooth muscle.
• Dilate coronary arteries and increase myocardial blood flow.
• Dilate peripheral arteries and reduce afterload.
Examples: Dihydropyridines (nifedipine), verapamil, diltiazem
Dihydropyridines have greater specificity for relaxing vascular smooth muscle
Verapmail and diltiazem have greater effects on cardiac pacemaker tissues
Major adverse effects include headache, hypotension, reflex tachycardia; risk of
heart block of cardiac failure particularly with verapamil or diltiazem
Also used for hypertension and arrhythmia

14. Aspirin
• Prevent platelet aggregation.
• Use for prophylaxis of blood clots particularly
in unstable angina.

15. Surgical treatment
• Coronary angioplasty
• Uses a balloon catheter to open occluded blood vessels
• Usually performed under local anesthetic
• 5% mortality, high rate of vessel re-occlusion
• Use of metal “stents” in opened vessel reduces rate of
occlusion
Coronary artery bypass graft
• Revascularization procedure in which a blood vessel is taken from
elsewhere in the body and surgically sutured around a blocked
coronary artery
• May involve multiple (one to five) blood vessels
• Re-occlusion of transplanted vessel is possible

16. Myocardial Infarction
• Myocardial infarction or “heart attack” is an irreversible injury to and
eventual death of myocardial tissue that results from ischemia and
hypoxia.
• Myocardial infarction is the leading killer of both men and women in
the United States.
• Most heart attacks are the direct result of occlusion of a coronary
blood vessel by a lipid deposit. These lipid deposits may accumulate
to the point where they completely block a coronary vessel or, more
commonly, accumulated lipid plaques may break off from the
vascular endothelium and act as a thrombus that blocks a coronary
artery at a narrower point downstream. Prolonged vasospasm might
also precipitate a myocardial infarction in certain individuals.

17. Coronary Arteries for the heart
The two main coronary arteries supplying the
myocardium are:
1. the left coronary artery (which subdivides into the
left anterior descending and circumflex branches) and
2. the right coronary artery

18. • The left anterior descending artery supplies blood to
the bulk of the anterior left ventricular wall, while the
left circumflex artery provides blood to the left atrium
and the posterior and lateral walls of the left ventricle.
The right coronary artery provides blood mainly to the
right atria and right ventricles.
• Nearly 50% of all myocardial infarctions involve the left
anterior descending artery that supplies blood to the
main pumping mass of the left ventricle.
• The next most common site for myocardial infarction is
the right coronary artery, followed by the left
circumflex.

19. A myocardial infarction may be:
a) transmural, meaning it involves the full thickness
of the ventricular wall, or
b) subendocardial, in which the inner one third to
one half of the ventricular wall is involved.
Transmural infarcts tend to have a greater effect on
cardiac function and pumping ability since a greater
mass of ventricular muscle is involved.

20. Manifestations of myocardial
infarction
1. Severe chest pain and discomfort : Pressing or crushing
sensation often accompanied by nausea, vomiting, sweating
and weakness due to hypotension. A significant percentage of
myocardial infarctions are “silent” and have no symptoms.
2. Irreversible cellular injury: Generally occurs 20 to 30 minutes
after the onset of complete ischemia.
3. Release of myocardial enzymes such as creatine
phosphokinase (CPK) and lactate dehydrogenase (LDH) into
circulation from myocardial damaged cells.

21. 4.Electrocardiogram changes : Inversion of T wave, ST
elevation, pronounced Q waves.
5.Inflammatory response from the injured myocardium :
Leukocyte infiltration, increased white blood cell
counts, fever.
6. Coagulative necrosis of the area of the myocardium
affected by the infarction.
7. Repair of damaged areas occurs by replacement with
scar tissue and not functional muscle tissue; therefore,
some alteration in function is inevitable

22. Complications of myocardial
infarction
Depending on the extent of the area involved in a myocardial
infarction, a number of complications might arise, including:
1. Rupture of weakened myocardial wall. Bleeding into pericardium
may cause cardiac tamponade and further impair cardiac pumping
function. This is most likely to occur with a transmural infarction.
Rupture of the septum between the ventricles might also occur if
the septal wall is involved in the infarction.
2. Formation of a thromboembolism from pooling of blood in the
ventricles.
3. Pericarditis : Inflammation due to pericardial friction rub. Often
occurs 1 to 2 days after the infarction.
4. Arrhythmia : Common as a result of hypoxia, acidosis and altered
electrical conduction through damaged and necrotic areas of the
myocardium. May be life-threatening and lead to fibrillation.

23. 5. Reduced cardiac function : Typically presents with reduced
myocardial contractility, reduced wall compliance, decreased
stroke volume and increased left ventricular end diastolic
volume.
6. Congestive heart failure: may result if a large enough area of
the myocardium has been damaged such that the heart no
longer pumps effectively.
7. Cardiogenic shock : Marked hypotension that can result from
extensive damage to the left ventricle. The resulting
hypotension will trigger cardiovascular compensatory
mechanisms that will further tax the damaged myocardium
and exacerbate impaired function. Cardiogenic shock is
associated with a mortality rate of 80% or greater.

24. Compensatory mechanisms of
myocardial infarction
As a result of the hypotension and hemodynamic changes that accompany a
myocardial infarction, the cardiovascular system initiates a number of
reflex compensatory mechanisms designed to maintain cardiac output
and adequate tissue perfusion :
1.Catecholamine release : Increases heart rate, force of contraction and
peripheral resistance.
2. Sodium and water retention.
3. Activation of renin–angiotensin system leading to peripheral
vasoconstriction.
4. Ventricular hypertrophy.
Unfortunately, these compensatory changes may increase oxygen demand and
workload on the infarcted heart and worsen overall cardiac function.

25. Treatment for myocardial infarction
1. Oxygen : Used to maintain blood oxygenation as well as
tissue and cardiac O2 levels.
2. Aspirin : If administered when myocardial infarction is
detected, the antiplatelet properties of aspirin may reduce
the overall size of the infarction.
3. Thrombolytic therapy :If employed in the first 1 to 4 hours
following the onset of a myocardial infarction, these drugs
may dissolve clots in coronary blood vessels and re-
establish blood flow.
4. Vasodilator drugs : Intravenous nitroglycerin can increase
blood flow to the myocardium and reduce myocardial work.

26. 5.β -Blockers : Blunt the effect of catecholamine release on the
myocardium, reduce heart rate and myocardial work.
6. Pain management : Sublingual nitroglycerin, morphine if
necessary
7. Antiarrhythmic drugs : To treat and prevent a number of
potentially life-threatening arrhythmias that might arise
following a myocardial infarction.
8. ACE inhibitors : the negative effects of vasoconstriction and
salt and water retention on the myocardium.

27. Thrombolytic Agents Used Clinically
a. Streptokinase : Derived from β -hemolytic streptococcus
bacteria; involved in the activation of plasmin
b. Anistreplase (APSAC) : Complex of human lys-plasminogen
and streptokinase; Administered as a prodrug
c. Alteplase (TPA): Recombinant tissue plasminogen activator
d. Urokinase : Endogenous human enzyme that converts
plasminogen to active plasmin
e. Routes of administration : Intravenous. for all of the above
f. Major unwanted effects : Internal bleeding,
gastrointestinal bleeding, stroke, allergic reactions

28. •Thank You