Ischemic Heart Disease [risk factors, manifestations, dx]; Rehabilitation in cardiology

Question 1

How does Myocardial ischemia occur?

Answer 1

When there is a difference between Oxygen demand and Oxygen supply for the myocardium, Myocardial ischemia and Ischemic Heart Diseases occur

Question 2

Major cause of Ischemic Heart Disease?

Answer 2

Atherosclerosis and plaque formations/ruptures. These reduce the coronary vessel lumen and based on the extent of stenosis, symptoms like angina, MI occur either during physical activity or at rest

Question 3

Broad classification of Ischemic Heart Disease

Answer 3

Chronic or Stable IHD:
- Obstructive Coronary Artery Disease
- Non-obstructive Ischemic Coronary Artery disease

Acute IHD/Coronary Syndrome:
- STEMI
- NSTEMI or Unstable Angina
- MI with non-obstructive Coronary Artery

Question 4

Clinical Features of IHD

Answer 4

Angina:
- Most significant symptom for CAD
- Retrosternal pain or pressure that does not alter with change in posture or respiration
- Intensity can increase
- Brought on by physical activity/stress or cold
- Patient become symptomatic when > 70% of Coronary artery has stenosis

Stable Angina:
- Predictable and reproducible angina episode
- Occurs at a particular level of physical activity or stress, which is individualistic to a patient
- No angina at rest, and symptoms are relieved after few mins of rest or via Nitroglycerine administration

Angina associated symptoms in IHD:
- Radiation of pain towards left shoulder, left arm, left jaw, epigastric pain, left shoulder blades
- Dizziness
- Dyspnea
- Autonomic symptoms like syncope, nasuea, diaphoresis
- Restlessness, anxiety

Unstable Angina:
- Angina that occurs at rest and is unpredictable
- Usually due to > 70% stenosis or plaque ruptures leading to minor or major occlusions in coronary arteries
- Symptoms similar to above

Untreated IHD can lead to MI or even cardiac death/arrest

Question 5

Risk factors

Answer 5

Any disease process that leads to atherosclerosis or impaired flow of blood to coronary arteries will cause IHD

Risk Factors include:
- Family History
- Diabetes Mellitus
- HTN
- Hyperlipidemia
- Obesity
- Advanced Age
- Smoking

Question 6

Dx approach to IHD or patients presenting with Angina symptoms with no history of previous CAD

Answer 6

Initial Evaluation:
- Physical Exam and Patient history
- Resting ECG [to differentiate between stable and unstable angina, previous MI or catch ecg changes when angina occurs]
- Pretest Probability scoring of CAD [based on Age, Sex and symptoms]
- Identifying traditional ASCVD risk factors [like DM]

Further Evaluation:
- Obvious non-cardiac causes do not require further workup
- Non invasive cardiac tests [Exercise Stress Test - Exercise ECG monitoring; Exercise stress imaging like echo, MI perfusion and CMRI | Pharmacological Stress Tests using dobutamine and ECG monitoring or Exercise stress imaging | Cardiac Anatomic tests like CCTA, CAC scoring]
- Invasive Cardiac Tests [Coronary Angiography - GOLD standard to diagnose CAD]

CCTA - Coronary CT Angiography
CAC - Coronary Artery Calcium score [amount of Calcium deposits in coronary artery walls]

Question 7

What is Cardiac Rehabilitation?

Answer 7

It is a professionally supervised rehabilitation program that includes medical evaluation, physical activity and lifestyle education to improve the quality of life for cardiac patients post MI, PCI, surgery, etc

Question 8

What all is included in a traditional Cardiac Rehabilitation program?

Answer 8

• Nutritional Therapy
• Weight loss program
• Lipid abnormality management
• Diet and medication management
• Blood pressure control
• Diabetes control
• Stress management
• Smoking cessation

Question 9

What does a typical Cardiac Rehabilitation team consist of?

Answer 9

• Cardiologists
• Nurses
• Dieticians
• Physical Therapists
• Mental Health Specialists

Question 10

Give basics of 3 phases in secondary prevention under Cardiac Rehabilitation?

Answer 10

Phase 1:
- After treatment in hospital
- Inpatient cardiac rehabilitation
- About 1 week
- Supportive counselling, mobilization guidelines, appropriate referals, discharge planning

Phase 2:
- Outpatient cardiac rehabilitation
- About 6-8 weeks
- Aim is to regain functional ability

Phase 3:
- Maintainence phase
- Continuation of activity and behaviours learned in Phase 2
- Reduction in risk of subsequent coronary events, reduce progression of atherosclerosis, reduction in morbidity and mortality