Ischemic Heart Disease (IHD – coronary Heart Disease) Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 1

objectives: At the end of this session the trainee will be able to be able to discuss the burden of IHD. describe essential elements in history taking & examination develop a differential diagnosis of chest pain. describe appropriate diagnostic testing for chest pain. discuss modifiable & non modifiable risk factors for cardiac disease. describe the use of investigation in the evaluation of a patient with chest pain. appropriatly use of specialty referral.

Prevalence of IHD Heart diseases responsible for overal deaths in the Saudi population: IHD : 17% Hypertensive heart disease 9% CVA : 4% 18th scientific session of the Saudi Heart Association. 2007 http://www.highbeam.com/doc/1G1-158905180.html 

History taking in CAD Patient characteristics (Name, age, sex,occupation) Pain (duration, location, intensity,nature,aggravating factors Associated symptoms (Dyspnea, syncope….etc) Past history (HPN,DM,COPD..ETC) Family history (coronary artery disease ,pneumothorax) Drug history (antiangina,anti diabetic..etc) Life style (Diet, exercise, alcohol, smoking ) Psychosocial (ICE, anxiety, stress )

What characteristics of the chest pain might make you more concerned for cardiac chest pain? Location Associated Symptoms Quality Chronology Onset Duration Intensity Exacerbating Relieving Situation

Physical Examination General Examination patient status: stable,notstable,inpain or not in pain. Vital signs. Obese or overweight. Skin appearance. Cardiovascular &respiratory system examination BP, Pulse rate, JVP. Chest :apex beat deviation, crepitations, decrease breath sounds. Heart : 1st & 2nd heart sounds, gallop, friction rub. Abdomen: tenderness, guadring….

Any exam findings that might help distinguish cardiac from non cardiac chest pain? General Appearance may suggest seriousness of symptoms. Vital signs marked difference in blood pressure between arms suggests aortic dissection Palpate the chest wall Hyperesthesia may be due to herpes zoster Complete cardiac examination pericardial rub Ischemia may result in MI murmur, S4 or S3 Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

What would be the differential diagnosis for chest pain?

Life threatening Causes Non-life threatening Causes Cardiovascular(16%): Myocardial infarct. Angina. Thoracic aortic dissection. Pulmonary (5%): Pulmonary embolus. Pulmonary infarction. Tension pneumothorax. Pneumonia. Pleurisy. Chest wall (33%): Trauma Fracture Costo-chondritis. Musculoskeletal. Gastrointistinal(20%): Esophageal spasm Esophagitis. Gall bladder disease. Peptic ulcer disease. pancreatitis Psychatric (9%): Anxiety. Spinal dysfunction: Cervical disease. Infections (rare): Herpes Zoster. ..

The risk factors for CAD Age > 45 (male) and >55 (female). Smoking. Family history. Hyperlipidemia. Diabetes. Hypertension. Obesity. Sedentary life style. Anxiety. Drug addiction. Past History.

Any tests that might help in diagnosis? History and Examination ECG Cardiac Enzymes Chest x-ray. Upper GI endoscopy.

Cont… ECG ST elevation of > 1mm or new Q in 2 leads Sensitivity 45% Above + ST depression or T-wave inversion Sensitivity 79% False positive rate = 17% 20% of patients having an MI will have a normal ECG initally

Cont… Cardiac enzymes: Troponin, CK, myoglobin 88-90% sensitive at 4-6 hours 95-100% sensitive 8-12 hours Source: Am Heart J 1998 Aug;136(2):237-44

LDL Level at Which to Consider Drug Therapy (mg/dL) Risk Category LDL Goal (mg/dL) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Level at Which to Consider Drug Therapy (mg/dL) CHD or CHD Risk Equivalents (10-year risk >20%) Very high risk <100 <70 (VHRP) 100 130 (100–129: drug optional) (< 100: drug optional) 2+ Risk Factors (10-year risk 20%) (moderately high risk pt ) 10-year risk < 10% <130 <100(theraputic option) 130 10-year risk 10–20%: 130 100-129 10-year risk <10%: 160 0–1 Risk Factor <160 160 190 (160–189: LDL-lowering drug optional)

Diabetes is regarded as a CHD Risk Equivalent 10-year risk for CHD  20% High mortality with established CHD High mortality with acute MI High mortality post acute MI

Initial Approach ABC assessment 100% Oxygen Aspirine Nitroglycerine IV access Morphine Monitoring ECG quickly MONA Morphine Oxygen Nitroglycerine Aspirine

Action Plan

Action Plan Source: http://www.aafp.org/afp/20050701/119.html

Referral Refer urgently all the serious conditions with chest pain: Cardiac causes. Esophageal spasm. Pulmonary embolism. Any other cases not responding to usual treatment.

Important Points The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain. A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain. Cardiac markers (troponin T, troponin I, and/or creatine kinase-MB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome. http://www.aafp.org/afp/20050701/119.html

Important Points A normal electrocardiogram does not rule out acute coronary syndrome. When used by trained physicians, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (a computerized, decision-making program built into the electrocardiogram machine) results in a significant reduction in hospital admissions of patients who do not have acute coronary syndrome. http://www.aafp.org/afp/20050701/119.html