Ischemic Heart Disease Flashcards
IHD-CAD
Ischemic Heart Disease=Coronary Heart Disease
Patient has one or more symptoms, signs or complications from an inadequate supply of blood to the myocardium. This is usually due to obstruction of epicardial arteries due to atherthrombosis.
Angina Pectoris
Pectoris-described by Heberden in 1768, published in 1772
Stable Angina is predictable, on exertion, relieved by rest or nitroglycerin. Most patients with IHD will have angina sometime during their lives
diagnosis of IHD
Diagnosis usually made with angina plus one or more risk factors
Angina is a clinical diagnosis, not an anatomic one. It is the starting point of the careful evaluation of patients with chest discomfort.
Angina is NOT pain, it is usually mild discomfort, from the umbilicus to the top of the ear.
If you diagnose angina an EKG should be done to help risk stratify
The EKG could show ST-T changes or an old MI. It is most likely going to be normal.
Most patients will need a provocative test, a stress test, either with a treadmill or a pharmacologic agent coupled with imaging. The imaging could be ultrasound, a stress echo, or a nuclear isotope like Tcc (technetium Sestamibi).
angina onset
Angina may be present for years in your patient, or it may happen once prior to Sudden Death or an MI, within 4 weeks. Therefore recent onset angina is Unstable Angina, a medical emergency.
Angina comes on more frequently in cold air
angina vs IHD
Remember your diagnosis of angina is clinical, made at the patient’s side. It is NOT made by the treadmill, The testing confirms that the chest pain is due to IHD. Therefore typical CP in an 18 year old may be angina, but it does not indicate IHD.
Coronary Angiography, Cardiac Catheterization is indicated for 2 reasons:
- Angina that is interfering with your patient’s life despite medical therapy
- High risk patients without angina, when there is concern for developing ACS or Sudden Death, or survivors of Sudden Death.
Invasive treatment of IHD
involves PCI and CABG
PCI is Percutaneous Coronary Intervention
CABG is Coronary Artery Bypass Grafting
(Decision on which to preform is beyond our scope today)
LV systolic function and LVEF
LV Systolic function is assessed by various techniques that “visualize” the LV in Systole vs Diastole, the 2D image of which is called the Ejection Fraction (EF). Echocardiography is the most widely used tool to visualize the LV.
LVEF is directly related to longevity, lower EF, lower length of life. Not all patients with angina need their EF defined, only when it will make a difference in their clinical management.
IHD-Acute Coronary Symptoms
ACS is defined as Unstable Angina and Acute MI.
Unstable Angina is defined as:
- New Onset Angina-within 4 weeks of presentation
- Any change for the worse in pre-existing angina.
Myocardial Infarction may be:
- ST elevated MI- ST elevation in atleast 2 contiguous leads (coronary anatomy contiguous)
- Non ST elevated MI- no ST elevation, often with ST depression, downsloping, or horizontal, sometimes no ST changes.
angiograms and interventions mostly come via
the radial. Much fewer vascular complications.
The MI is diagnosed by
the typical rise and fall of troponin or other cardiac markers in a fashion consistent with cell death, coupled with a clinical presentation consistent with an MI.
The Chest discomfort with an MI is usually painful, lasts at least 20 minutes, rarely more then 6 hours, and usually the above ST changes.
Medical treatment of angina, unstable angina and ACS
varies with the diagnosis, subset (ie, stable angina vs unstable angina).
In general, stable angina pectoris of effort is best treated with risk factor modification, exercise, aspirin and sometimes more potent meds such as beta blockers or calcium channel antagonists.
Treatment of the Acute MI, NSTMI vs STMI
is usually medical stabilization then coronary angiography, not thrombolytics
the STMI is thrombolytics unless a cardiac cath lab is immediately available, when PCI is preferred.
EECP
External Enhanced Counter Pulsation is a proven treatment for chronic angina that improves endothelial function with a series of 35 treatments over 7 weeks
