2. Definition
• (IHD), myocardial ischemia or
CAD(coronary heart disease)is a
disease characterized by ischemia
(reduced blood supply) to the heart
muscle,
usually due to coronary artery disease
(atherosclerosis of the coronary
arteries obstruction )
3. • Imbalance between Myocardial
oxygen supply and demand.
• Myocardial hypoxia and
accumulation of waste metabolites
due to atherosclerotic disease of
coronary arteries
• Most occurs because of
atherosclerotic plaque with in one or
more coronary arteries
5. Etiology and Pathophsiology
• The disease process underlying
most ischemic heart disease is
atherosclerosis of the coronary
arteries.
• The arteries become "furred up"
by fat-rich deposits in the vessel
wall (plaques).
6. Epidmiology
• IHD Is the number one killer in USA and
worldwide
• Every minute an American dies of CAD
• 37% who experience acute coronary
syndrome will die of it in the same year
• Since 1968 CAD decreased annually –from
1980 to 2000 CAD reduced to half proper
treatment and improved risk factors
• Still 1/6 death is due CAD
• Still CAD affecting 16 million American
• CAD increased by age
7. Angina pectoris
• Is the most common cardiac pain, it is usually
due to myocardial ischemia from obstructed
flow in coronary vessels .
But can occur by other conditions
• Aortic stenosis
• Hypertrophy
• Cardiomyopathy
• Chest pain lasting less than 10 minutes
8. Chronic Stable angina
is due to inability to supply the myocardium
(heart muscle) with sufficient blood in situation
of increased cardiac output (such as
exertion).due to
1-Atherosclerosis
2- coronary vasospasm may occur at the site of a
lesion
3-less frequently normal vessels
4-congenital ,emboli, arthritis ,dissection of
aorta or infarction,
9. Angina may also occur by
-Hypertrophy cardiomyopathy
-Aortic stenosis,
-Aortic regurgitation,
-Hyperthyroidism ,
-Anemia ,
-PAT, V.tach,
Another kind of Angina called X –syndrom
Which cause by (microvasculature disease ) is
difficult to diagnosis.
Treatment is often not succeful,
prognosis is good
12. Prinzmetal (variant)Angina
• Is a syndrome – usually results from coronary
vasoconstriction
• It tends to involve mostly RCA ,and there may
be no fixed stenosis
• Chest pain may occur with out precipitating
factor
• Is associted St.segment elelvation rather than
deprssion
• Mostly affect womens under 50years of age
13. • Mostly occur early morning ,awake patient
from sleep ,may be with arrhythmias
Treatment
• Aggressive medical treatment
,revascularization, if no stenosis than stop
smoking or
• use of cocaien precipitate pain
• Respond well with nitrate-Ca chanel blockers
( ,nifidipien,diltiazem,amlodipine)
• Beta blocker,
14. Canadian CV society functional
classification of stable angina
Grade 1-
physical activity, walking,climbing staires,not
cause angina
Grade2-
Slight limitation of ordinary activity
Walking or climbing stairs rapidly ,walking up
hill,in cold ,in wind,or when in under
emotional stress ,or after heavy meals or after
walking few hours after walking cause pain
15. Grade 3
Marked limitation of ordinary physical activity
walking 1-3 blocks on the level
And climbing less than one flight in normal
condition
Grade 4-
• Inability to carry on any physical activity with
out discomfort ,angina ,may be present at rest
16. Symptoms
Depend of
• past history
• Circumstances (activities, relief by rest)
Character of pain
Pt .not refer angina as pain,
but as sensation,tightness,squeezing,burning
,pressing,choking,aching,bursting,gas
(indigestion),
Some times clenching in the middle of chest.
Location and radiation
.duration is short less than 3minute
19. Is in short duration ,
Some times start after heavy meals
If more than 30 minutes than MI,
unstable angina reliev by taking Nitro-And
diagnositic .relieve and subsides
SIGNS.
Bp may up or down,
tachycardia or more bradycardia
Gallop rhythm,
sysytolic murmur(MR,papilary muscle dysfunction)-
-SVT,or V.Tach
20. Diagnosis
• Lab-(CK-MB),Troponin ,Anemia
,Hyperlipdemia
• ECG- some time normal,or st depresion ,T
wave inversion or flatened T waves,
• History ,clinical symptomes,
• Non invassive TMT is important bruce
protocole
• Or TMT- stress echo-nuclear ,MRI
21. Stress test
Precaution –indication –contra indication
• Myocardial stress imaging
-when TMT not gave us final result-LBBB
-when clinical and test is not matching
-to localize the region
-to assess the completeness of vascularization
after bypass or angiogram
-as prognostic indicator with any known CAD
22. .ACS (Acute coronary syndrom)
Unstable angina,
STEMI and NSTEMI are attributed to
"plaque rupture", where one of the
plaques gets weakened, develops a tear,
and forms an adherent blood clot that
either obstructs blood flow or floats
further down the blood vessel, causing
obstruction there
23. Effect Of Ischemia
• (IHD) Ischeamic heart disease may be present
with any of the following problems:
• Angina pectoris
(chest pain on exertion, in cold weather or
emotional situations)
• Acute chest pain:
(ACS)acute coronary syndrome, unstable angina or
myocardial infarction("heart attack", severe chest
pain unrelieved by rest associated with evidence
of acute heart damage)
• Heart failure
• (difficulty in breathing or swelling of the
extremities due to weakness of the heart muscle)
24. Diagnosis
• The diagnosis of ischaemic heart disease
underlying particular symptoms depends largely
on the nature of the symptoms.
• The first investigation is an electrocardiogram
(ECG/EKG), both for "stable" angina and acute
coronary syndrome.
• An X-ray of the chest
• Blood tests may be performed.
• Myeloperoxidase has been proposed as a
biomarker
25. Prevention
• Various treatments are offered in people
deemed to be at high risk of coronary artery
disease.
• These include control of cholesterol levels in
those with known high cholesterol,
• smoking cessation,
• dietary intervention (especially eating more
vegetables and less meat),[
• and control of high blood pressure.
• Regular Exercise
26. Management
• In stable IHD,
• Anti anginal drugs may be used to reduce the rate
of occurrence and severity of angina attacks.
• Treatments for acute coronary syndrome and
established coronary artery disease is discussed
above in "diagnosis".
• Revascularization for acute coronary syndrome
has a significant mortality benefit.
• Recent evidence suggests that revascularization
for stable ischeamic heart disease may also
confer a mortality benefit over medical therapy
alone.[]
27. • Treatment of coronary artery disease includes
addressing "modifiable" risk factors.
• This includes suppression of cholesterol
(usually with statins), even in those with
statistically normal cholesterol levels, control
of blood pressure, blood sugars (if diabetic),
and regular exercise.
• Smokers are encouraged to stop smoking.
• Diet plays a major role in the progression of
coronary artery disease and by making certain
diet choices a person can drastically change
their chance of dying from it.
28. Treatment
• Drug therapy is commonly used for treatment of
ischemic heart disease and includes:
• Angiotensin receptor blockers (ARBs), which lower
blood pressure,losartan
• Anti-ischemic agents such as ranolazine (Ranexa)
• Antiplatelet drugs, which prevent the formation of
blood clots
• Beta-blockers, which lower the heart rate
• Calcium channel blockers, which reduce workload on
the heart muscle
• Nitrates, which dilate the blood vessels
• Statins, which lower cholesterol
29. • Surgical procedures used to treat ischemic
heart disease
• Severe symptoms that are not relieved by
medication alone are treated with surgical
procedures including:
• Angioplasty and stent placement (procedure to
remove plaque and restore blood flow in
clogged arteries)
• Coronary artery bypass graft (procedure that
helps restore blood flow to the heart by routing
the flow through transplanted arteries)
30. • What you can do to improve your ischemic
heart disease
• In addition to following your treatment
plan, you may be able to improve your
ischemic heart disease by:
• Getting regular physical activity
• Keeping your cholesterol at a healthy level
• Maintaining normal blood pressure
• Quitting tobacco use
• Reducing cholesterol and fat in your diet
31. • What are the potential complications of
ischemic heart disease?
• You can help minimize your risk of serious
complications by following the treatment plan
you and your health care professional design
specifically for you.
Complications of ischemic heart disease
include:
• Arrythmia (irregular heart rhythm)
• Heart damage
• Myocardial infarction (heart attack)
