Ischaemic Heart DiseaseIschaemic Heart Disease

Aims and ObjectivesAims and Objectives

IschaemicIschaemic heartheart diseasedisease– Definition, manifestations, epidemiology, Definition, manifestations, epidemiology,

aetiology, pathophysiology, risk factors and aetiology, pathophysiology, risk factors and preventionprevention

ChestChest painpain– Differential diagnosisDifferential diagnosis

AcuteAcute myocardialmyocardial infarctioninfarction– Assessment, treatment, complicationsAssessment, treatment, complications

CardiopulmonaryCardiopulmonary resuscitationresuscitation

Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition

Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition

An imbalance between the An imbalance between the supplysupply ofof oxygenoxygen and the and the myocardialmyocardial demanddemand resulting in myocardial ischaemia.resulting in myocardial ischaemia.

AnginaAngina pectorispectorissymptom not a diseasesymptom not a diseasechest discomfort associated with abnormal chest discomfort associated with abnormal myocardial function in the absence of myocardial function in the absence of myocardial necrosismyocardial necrosis

Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition

SupplySupply– Atheroma, thrombosis, spasm, embolusAtheroma, thrombosis, spasm, embolus

DemandDemand– Anaemia, hypertension, high cardiac Anaemia, hypertension, high cardiac

output (thyrotoxicosis, myocardial output (thyrotoxicosis, myocardial hypertrophy)hypertrophy)

Ischaemic heart diseaseIschaemic heart diseaseManifestationsManifestations

Sudden deathSudden death Myocardial infarctionMyocardial infarction Acute coronary syndromeAcute coronary syndrome Stable angina pectorisStable angina pectoris Heart failureHeart failure ArrhythmiaArrhythmia AsymptomaticAsymptomatic

Ischaemic heart diseaseIschaemic heart diseaseAetiologyAetiology

FixedFixed– Age, Male, +ve family historyAge, Male, +ve family history

ModifiableModifiable – – strong associationstrong association– Dyslipidaemia, smoking, diabetes mellitus, Dyslipidaemia, smoking, diabetes mellitus,

obesity, hypertensionobesity, hypertension ModifiableModifiable - - weak associationweak association

– Lack of exercise, high alcohol consumptionLack of exercise, high alcohol consumption

Atherosclerosis

Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology

Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology

Response to injury hypothesisResponse to injury hypothesis ATHEROSISATHEROSIS

Accumulation of cholesterol within the vessel wall intima. Accumulation of cholesterol within the vessel wall intima. Smooth muscle cell proliferationSmooth muscle cell proliferation

SCLEROSISSCLEROSISExpansion of fibrous tissueExpansion of fibrous tissue

INFLAMMATIONINFLAMMATIONChronic inflammatory cells migrate into wall, release Chronic inflammatory cells migrate into wall, release cytokinescytokines

GROWTH FACTORS/INFLAMMATORY MEDIATORSGROWTH FACTORS/INFLAMMATORY MEDIATORS

Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology

An atherosclerotic lesion

a

Schematic illustration

Endothelium Smooth muscle cell

Macrophage foam cellThrombus formation

Media(smooth muscle cells)

Lymphocytes

Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes

AtherosclerosisAtherosclerosis

Fatal / non-fatal AMI Unstable

angina

CoronaryArtery spasm

Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes FatalFatal AMIAMI

Small, fat rich plaques. Plaque RUPTURE. Small, fat rich plaques. Plaque RUPTURE. Thrombus in lipid core and on plaques surface. Thrombus in lipid core and on plaques surface. Vessel lumen OCCLUDED. Vessel lumen OCCLUDED.

NonNon--fatalfatal AMIAMIPlaque EROSION rather than rupture. OCCLUSIVE Plaque EROSION rather than rupture. OCCLUSIVE thrombus. thrombus.

UnstableUnstable anginaanginaUsually mod-severe stenosis. Multiple vessels. Collaterals Usually mod-severe stenosis. Multiple vessels. Collaterals often formed. Thrombus formation and vasoconstriction. often formed. Thrombus formation and vasoconstriction. Myocardial infarction may ensueMyocardial infarction may ensue..

Ischaemic heart diseaseIschaemic heart diseaseRisk factors and preventionRisk factors and prevention

Family HistoryFamily History SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus HypercholesterolaemiaHypercholesterolaemia Lack of exerciseLack of exercise

PRIMARY PREVENTIONPRIMARY PREVENTION

Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia

SiteSiteJaw to navel, retrosternal, left Jaw to navel, retrosternal, left submammarysubmammary

RadiationRadiationLeft chest, left arm, jaw….mandible, Left chest, left arm, jaw….mandible, teeth, palateteeth, palate

QualityQuality//severityseveritytightness, heaviness, compressiontightness, heaviness, compression

Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia

Precipitating/relieving factorsPrecipitating/relieving factors

physical exertion, cold windy weather, physical exertion, cold windy weather, emotionemotion

rest, sublingual nitratesrest, sublingual nitrates Autonomic symptomsAutonomic symptoms

sweating, pallor, peripheral sweating, pallor, peripheral vasoconstriction, nausea and vomitingvasoconstriction, nausea and vomiting

Acute Myocardial InfarctionAcute Myocardial Infarction

Acute Myocardial InfarctionAcute Myocardial InfarctionAssessmentAssessment

Symptoms and signs of myocardial Symptoms and signs of myocardial ischaemiaischaemia

AlsoAlso– Changes in heart rate /rhythmChanges in heart rate /rhythm– Changes in blood pressureChanges in blood pressure

Acute Myocardial InfarctionAcute Myocardial InfarctionConfirming the diagnosisConfirming the diagnosis

Typical chest painTypical chest pain

Electrocardiographic changesElectrocardiographic changes– ST elevationST elevation– new LBBB (left bundle branch block)new LBBB (left bundle branch block)

Myocardial enzyme elevationMyocardial enzyme elevation– Creatine kinase (CK-MB)Creatine kinase (CK-MB)– TroponinTroponin

Acute Myocardial InfarctionAcute Myocardial InfarctionTreatmentTreatment

Rest, sit up and reassure patientRest, sit up and reassure patient OxygenOxygen Analgesia (opiate, sublingual Analgesia (opiate, sublingual

nitrate)nitrate) AspirinAspirin Prepare for basic life supportPrepare for basic life support

Acute Myocardial InfarctionAcute Myocardial InfarctionMedical treatmentMedical treatment

Rest, oxygen, analgesia, aspirinRest, oxygen, analgesia, aspirin ThrombolysisThrombolysis Primary angioplastyPrimary angioplasty Beta-BlockersBeta-Blockers ACE inhibitorsACE inhibitors

Acute Myocardial InfarctionAcute Myocardial InfarctionComplicationsComplications

Death (Death (18% within 1 hour,18% within 1 hour, 36% within 24 hours)36% within 24 hours) Non-fatal arrhythmiaNon-fatal arrhythmia Acute left ventricular failureAcute left ventricular failure Cardiogenic shockCardiogenic shock Papillary muscle rupture and mitral Papillary muscle rupture and mitral

regurgitationregurgitation Myocardial rupture and tamponadeMyocardial rupture and tamponade Ventricular aneurysm and thrombusVentricular aneurysm and thrombus