Dr. Sohail Bashir Sulehria Assistant Professor (Medicine) KEMU/ Mayo Hospital Lahore

Ischemic Heart Disease & its Management 4/26/20172/11/2009

The coronary arteries.

Ischemic Heart Disease   Ischemic Heart Disease  ischemic heart disease (IHD): is a disease characterized by  reduction of blood supply of the heart muscle, usually due to coronary artery disease  2-Myocardial infarction STEMI NSTEMI 1-Angina Stable Angina Unstable Angina Variant Angina decubitus angina nocturnal angina

Epidemiology • most common cause of cardiovascular morbidity and mortality • atherosclerosis and thrombosis are the most important pathogenetic mechanisms. • peak incidence of symptomatic IHD is age 50-60 (men) and 60-70 (women) M>F

Etiology 1- Decreased coronary blood flow due to mechanical obstruction such as: Atheroma Spasm of coronary artery Thrombosis Embolism Coronary artreritis 2- Increased myocardial oxygen requirement : Increased cardiac output :thyrotoxicosis Myocardial hypertrophy: aortic stenosis , hypertension 3- Decreased flow of oxygenated blood : anemia

Risk Factors Uncontrollable Controllable Sex Hereditary Race Age High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Mellitus Stress and anger

Angina Pectoris At least 70% occlusion of coronary artery resulting in pain. What kind of pain? Chest pain Radiating to: Left shoulder Jaw Left or Right arm Usually brought on by physical exertion as the heart is trying to pump blood to the muscles, it requires more blood that is not available due to the blockage of the coronary artery(ies) Is self limiting usually stops when exertion is ceased

Angina Pectoris Continued Angina Pectoris can be Stable or Unstable: Stable: The pain and pattern of events is unchanged over a period of time (months years) Unstable: The pain and pattern is changing, be it in duration, intensity or frequency A Myocardial Infarction waiting to happen

Myocardial Infarction Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels

Myocardial Infarctions: Statistics 250,000 deaths per year. 30% mortality within the first 2 hours 45 Minutes of Ischemia: Cardiac muscle death occurs How is the Diagnosis Made? Electrocardiographic changes ST elevation Myocardial enzyme elevation Creatine kinase Troponin C Reactive Protein ECHO ETT ANGIOGRAPHY THALIUM SCAN

Complications of M I Infarction leading to inability of the heart to function properly leading to Heart Failure Angina/Pain Cardiogenic shock Ventricular aneurysm and rupture Embolism Formation Arrhythmias  Myocardial Infarctions can lead to Ventricular Fibrillation (shockable!)

Sudden Death Sudden Death : 250,000 deaths in the US per year are caused by what is referred to as “sudden” cardiac death Sudden Cardiac Death is also known as a “Massive Heart Attack” in which the heart converts from sinus rhythm to ventricular fibrillation In V-Fib, the heart is unable to contract fully resulting in lack of blood being pumped to the vital organs V-Fib requires shock from defibrillator “SHOCKABLE RHYTHM”

Treatment Many people are able to manage coronary artery disease with lifestyle changes and medications. Other people with severe coronary artery disease may need angioplasty or surgery.

Management of Ischemic Heart Disease: Lifestyle: Diet Exercise Preventive treatment Low fat, low cholesterol diet Cessation of smoking Red wine (in moderation)

Management of Ischemic Heart Disease: Pharmacological Agents: Beta Blockers Act either selectively or non-selectively on Beta receptors: Beta 1 cardiac muscle  increase rate and contraction Beta 2 dilates bronchial smooth muscle Ca++ Channel Blockers Acts on vasculature blocking Ca++ and causing vasodilation Nitrates Vasculature vasodilation Anti-Hypercholesterolemia HMG CoA Reductase Inhibitors  reduction in “manmade” cholesterol thus helping to reduce atheroma formation Antiplatelet Medication: Clopidogrel (Plavix) Aspirin

Surgical Treatment Stenting Angioplasty (balloon) Bypass surgery

                                                                                                                                                

Thank You