Clinical Presentations of Ischemic Heart Disease Flashcards
➤ At IHD’S root it is related to the formation of
____ (hardening of the arteries) in the walls
of the coronary arteries
➤ ___ in other vessels is responsible for
stroke, peripheral arterial disease, erectile
dysfunction, etc etc
➤ At it’s root it is related to the formation of
atheroma (hardening of the arteries) in the walls
of the coronary arteries
➤ Atheroma in other vessels is responsible for
stroke, peripheral arterial disease, erectile
dysfunction, etc etc
which sex is more affected by ihd
men
Lifetime risk at age 40 years approaches 1/2 for
men and 1/3 for women
conventional CAD risk factors
+ sedentary lifestyle, diet low in fruits and vegetables
outline the mechanism behind ischemic heart disease:
➤ ____ __
____ (lipids) are
deposited in vessel wall
➤ Inflammatory response
triggers ____ to
consume lipid and
become ‘___ cells’
➤ A fibrous cap forms
overlying the plaque,
and ___ ___ are
laid
➤ Progressive coronary
narrowing occurs over
years
➤ LOW DENSITY LIPOPROTEINS (lipids) are
deposited in vessel wall
➤ Inflammatory response
triggers MACROPHAGES to
consume lipid and
become ‘FOAM cells’
➤ A fibrous cap forms
overlying the plaque,
and calcific deposits are
laid
➤ Progressive coronary
narrowing occurs over
years
what is angina
Severe narrowing of a coronary can result
in ‘ischemia’ of myocardium under
conditions of increased demand
- Angina is the name given to the symptoms
that result from this myocardial ischemia,
and is analogous to the calf pain
experienced during intense biking
- • At rest, they might be getting an adequate supply, but under stress, schema might occur because there is not enough supply.
development of acute coronary syndrome (ACS)
- rupture or disturbance of a vulnerable plaque leads to exposure of blood components to __ __
2.__ forms within the vessel at the
site of endothelial injury
- Partial or complete occlusion of the artery
leads to myocardial __ and (if
sustained) myocardial __ - Technically it is called myocardial
infarction if there is ___ of the tissue
note: • The plaque is in the wall of the vessels, it’s not in the actual lumen. When the plaque from the wall ruptures, tissiue factor can Leak into the lumen and promote thrombus formation.
1. rupture or disturbance of a vulnerable plaque leads to exposure of blood components to tissue factor
2.Thrombus forms within the vessel at the
site of endothelial injury
- Partial or complete occlusion of the artery
leads to myocardial ischemia and (if
sustained) myocardial infarction - Technically it is called myocardial
infarction if there is necrosis of the tissue
general onset and duration of angina
➤ Fairly gradual in onset, usually over seconds or minutes as
myocardial oxygen demand outstrips supply
➤ Generally last for many seconds or several minutes,
depending on inciting event / activity
➤ Ischemic pain that lasts for hours should result in tissue
infarction (see next part of lecture)
location and radiation of angina
➤ Classically centre or left side of chest
➤ With radiation to left arm and jaw
➤ Can have primary location anywhere in the chest, but can be
most pronounced or primarily felt in the back, jaw or
epigastrium
T/f you can get angina if you don’t have CAD
false. you cannot get angina if you don’t have coronary artery disease. But you may get an increase in certain heart attack markers if you had intense exercise like a huge marathon or something
character of anginal pain
➤ Tightness, heaviness, squeezing, pressure, ‘weight on chest’
➤ Burning, warmth
➤ Numbness
➤ Non-descript or poorly characterized pain
aggrevating and alleviating factors of angina
➤ Traditionally brought on by exercise or activity
➤ Can also be triggered by emotional stress, eating, cold
exposure
➤ Classically alleviated by rest and use of nitroglycerin spray
associated symptoms of angina in additional to chest pain
dyspnea, diaphoresis, nausea.
note:
NOT ALL PATIENTS WITH ANGINA PRESENT WITH CHEST PAIN
➤ An ‘anginal equivalent’ is a symptom such as shortness of
___, diapho____resis, extreme ____, or pain in a site other
than the chest occurring in a patient at high cardiac risk.
Anginal equivalents are considered to be (potential)
symptoms of myocardial ischemia
➤ More common in ___, ___, and the __
NOT ALL PATIENTS PRESENT WITH CHEST PAIN
➤ An ‘anginal equivalent’ is a symptom such as shortness of
breath, diaphoresis, extreme fatigue, or pain in a site other
than the chest occurring in a patient at high cardiac risk.
Anginal equivalents are considered to be (potential)
symptoms of myocardial ischemia
➤ More common in females, diabetics, and the elderly
standard definition of typical angina (3). what happens if it doesn’t meet all three?
- retrosternal chest discomfort with characteristic quality and duration
- brought on by exertion or emotional stres
- alleviated by rest or nitroglycerin.
Atypical chest pain: meets 2 of the 3
non-cardiac chest pain: meets 1 or less criteria
common tests to diagnose coronary artery disease (CAD)
stable angina (3 characteristics)
stable angina:
- predictable pain
- no rest pain
- no change in frequency, severity or duration.
remember: Ty p i c a l A n g i n a
1. Retrosternal chest discomfort with characteristic quality and duration 2. Brought on by exertion or emotional stress 3. Alleviated by rest or nitroglycerin
outline the 4 classifications of angina classes.
causes of angina
note:
Chest pain is the second most common reason for presentation to the ER after abdominal pain. Acute coronary syndrome is the final diagnosis in 10-30% of these visits.
- BUT: Chest pain is only seen in ACS 1/3 of the time– ACS doesn’t always present with CP! WATCH FOR ANGINAL EQUIVALENTS:
➤ An ‘anginal equivalent’ is a symptom such as shortness of
breath, diaphoresis, extreme fatigue, or pain in a site other
than the chest occurring in a patient at high cardiac risk.
Anginal equivalents are considered to be (potential)
symptoms of myocardial ischemia
➤ More common in females, diabetics, and the elderly
what are the 5 factors taken into consideration on the “hear score for ACS” classification
- age
- risk factors (HTN, DM, dyslip, FH, smoking, obesity)
- History
- ECG
- Troponin
the higher the score, the higher the likelihood ratio that it’s ACS.
which one is ST depression, normla or elevation?
what’s going on?
In LBBB, the normal direction of septal depolarisation is reversed (becomes right to left), as the impulse spreads first to the RV via the right bundle branch and then to the LV via the septum.
This sequence of activation extends the QRS duration to > 120 ms and eliminates the normal septal Q waves in the lateral leads.
LBBB+ chest pain = STEMI
inferolateral ST depression
inferolateral and posterior ST elevation
STEMI on ECG shows 2 characteristics features:
- ST elecation
- LBBB on V2 lead
T/F an elevated troponin is suggicient to diagnose ACS
false.
➤ An elevated troponin is not sufficient to diagnose ACS (see
last slide and next slide…)
➤ Serial biomarkers are generally needed as it can take several
hours for troponin to become positive
➤ Previously less specific markers than troponin had been used
(Only one you are likely to hear of would be CK-MB)
TO DIAGNOSE ACUTE MYOCARDIAL INFARCTION, you need:
- elevated troponin
- plus one or more of:
➤ Symptoms of ischemia
➤ ECG changes of ischemia (ST-T changes, new LBBB)
➤ Development of pathologic Q waves on ECG
➤ Imaging evidence of wall motion abnormality or loss of
viability
➤ Once you’ve made a diagnosis of ACS, it is important to
understand the patients level of risk of:
➤ Death
➤ Reinfarction
➤ Major complication
What are the major predictors of risk?
note:
GRACE Risk Score
➤ Age, Heart Rate, Systolic Blood
pressure, Killip Class (heart failure or
shock), ST deviation, cardiac arrest at
presentation, serum creatinine,
cardiac enzyme elevation
SEE SLIDES
after establishing ABCs, you should give ____ stat as an antiplatelet agent
ASA STAT!!!
-➤ A second anti
platelet agent is
added to ASA in
all ACS patients
without
contraindication
➤ Such as
clopidogrel or
Ticagrelor
ASA is used stat with someone with ACS. ASA is also used long-term in stable CAD.
- a second antiplatelet agent is added to ASA in all ACS patients without contraindication, such as ___ or ___
clopidogrel or ticagrelow.
____ ____ in ACS is both diagnostic and therapeutic procedure which is commonly employed in ACS cases.
