Transcript Ischemic Heart Disease

Ischemic heart Disease
Dr. Rehab F. Gwada
Objectives of the Lecture
• The student at the end of this lecture will be able
 To define Ischemic heart disease (IHD)& identify
associated risk factors according to scientific rational
 To describe its causes &pathogenesis.
 To differentiate between angina &AMI .
 To explain sign & symptoms associated with IHD
 to diagnose IHD according to scientific base.
 To describe the strategies of management in patient
with IHD according to scientific protocol.
Ischemic heart disease
Definition
Ischemic heart disease (IHD), or myocardial ischemia, or coronary
artery disease is a disease characterized by reduced blood
supply of the heart muscle, as a results of coronary
artery narrowing or blocked usually due to
atherosclerosis.
• Partially blocked it causes angina.
• Fully blocked it causes myocardial infarction
or a heart attack
Coronary obstruction/Cardiac pain/Cardiac
Ischemia lesion
Obstruction:
Impediment.
Stenosis  Narrowing
of blood vessle
Pain :
Cardiac lesions
Angina Pectoris
Ischemia fibrosis.
Pain :
Cardiac lesions
Narrow
lumen
I) Obstruction
II) Occlusion
Occlusion:
Closed
vessel
Infarct Pain
Closure
of the
lumen
Infarct (necrosis).
Coronary Arteries (CA)
• The blood supply to the heart is
provided by the right (RCA) &
left (LCA) coronary arteries
which arise from the base of the
aorta.
Review anatomy of CA
Atherosclerosis
• Atherosclerosis is a slow, progressive disease which
begins in childhood and takes decades to advance.
• In which patchy deposits of fatty material(atherosclerotic
plaque) develop in wall of arteries leading to reduced blood
flow .
• Plaque (the build-up of lipid/cholesterol, calcium
fibrin, cell debris) in the artery wall forms as a
response to injury to the endothelium in the artery
wall.
Atherosclerosis
Factors may injury endothelium cells lining the
arteries :
high BP
 elevated cholesterol and triglycerides(LDL)
 cigarette smoking
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Presentation of Ischemic heart
disease
• Depending on the degree & character of the
obstruction IHD results in :– Asymptomatic(silent)
– angina (stable &unstable)
– MI
– Heart failure.
– Arrhythmias
– sudden cardiac death
Angina
• Angina pectoris (chest pain on exertion, in
cold weather or emotional situations).
• It may be radiating
• Association : sweating , dizziness, may be
dyspnea (due to LVF)
• NB: Silent ischemia : Dyspnea, fatigue &
dizziness with no pain
Signs (during attack)
Usually no abnormal finding
• A positive Levine sign: the patient's fist clenched
over the sternum when describing the pain.
• Pallor, tachycardia & hypertension (sec. to
sympathetic stimulation)
• S1: weak
• S2:reversed splitting
• S3: due to LVF
• Murmur : due to papillary Ms. dysfunction
myocardial infarction
 myocardial infarction due to sudden , complete
cessation of blood supply .
 new onset, intensification, nocturnal, prolonged
chest pain unrelieved by rest
 IT associated with evidence of acute heart damage.&
difficulty breathing
 need intervention.
 Most deaths from heart attacks occur within 2
hours from the onset of symptoms
Ischaemia and Infarction
Non-STEMI
STEMI
Arrhythmia
• Arrhythmia: is an abnormality in the heart's rhythm or rate
• All types may occur
 Tachycardia: Fast heartbeat > 100 beats/min in the absence
of exercise or anxiety
 Brachycardia: Slow heartbeat < 60 beats/min
 Atrial flutter
 rapid, regular atrial rhythm
 ~ 300 beats/min
 Atrial fibrillation
 rapid, irregular atrial rhythm
 decreased CO
 Ventricular fibrillation
– extremely rapid & irregular
 Premature Atrial Contractions (PAC)
– Extra contraction or ectopic beats of atria
Atrial flutter
Atrial
fibrillation
Arrhythmia
 Premature ventricular contraction: Contraction of the
ventricles, that occurs earlier than usual because of
abnormal electrical activity of the ventricles. The
premature contraction is followed by a pause; the
contraction following the pause is usually more forceful
than normal. These more forceful contractions are
frequently perceived as palpitations.
• http://www.cardiachealth.org/premature-atrialcontractions-pacs
• https://www.youtube.com/watch?v=yIlwHtDszf0&list=
PLhSuwhfEcqes7ABCcafdt2LhyoY0hdm0p
Heart Failure
• Heart unable to pump sufficient blood to meet
metabolic needs of body
• Endpoint for
–
–
–
–
–
coronary atherosclerosis(most common cause)
HTN
valve disease
cardiomyopathy
congenital cardiac malformation
Heart Failure(CHF)
In LT ventricular failure, low CO causes
systemic hypoperfusion & pulmonary venous
congestion
RT ventricular failure causes systemic venous
congestion
Cardiac Arrest
• Cessation of all activity in the heart
• No conduction of impulses (flat line)
• May occur :
–
–
–
–
–
Arrhythmia  Ventricular fibrillation
Excessive vagal nerve stimulation (decreases heart)
Drug toxicity
Insufficient oxygen to maintain heart tissue
Massive Acute infarct
• Blood flow to heart and brain must be
maintained to resuscitate
Risk Factors for
Ischemic Heart Disease
• Age:
– Male > 45 years
– Female > 55 years or premature menopause
without estrogen replacement therapy
• Family History
• Sex
– male> female
Risk Factors for
Ischemic Heart Disease
• Hypertension
– Appears to weaken the artery wall at points
of high pressure leading to injury and
invasion of cholesterol.
• Cigarette Smoking
– It reduces high-density lipoproteins&
increase BP & HR.
Risk Factors for
Ischemic Heart Disease
o Diabetes
o Inactivity
o Sedentary person has double risk for
developing CHD as a person who is active.
o Obesity
Risk Factors for
Ischemic Heart Disease
• Abnormal Blood Lipids
The recommended level of LDL & HDL cholesterol for adults is less than 100
mg/dl & 60 mg/dl or more respectively .
Normal level of total cholesterol for adults is less than 200 mg/deciliter.
The National Cholesterol Education Program recommends that all
adults, beginning at age 20, have their lipoproteins measured at least
once every 5 years.
•
LDL Cholesterol (low density lipoprotein)
•
HDL Cholesterol (high density lipoprotein)
Differential Diagnosis
Dissecting aortic aneurysm
Esophageal spasm.
Musculoskletal chest pain
Diagnosis
•
•
•
•
•
•
The nature of the symptoms.
An electrocardiogram
Coronary angiogram
Stress testing
An X-ray of the chest
Cardiac enzymes {creatine kinase (CK), and
troponin (T)}.
• Echocardiogram
• Blood tests may be performed.
Strategies of Management
• Depending on the symptoms and risk:
 Modification of risk factors.
• Medication can be given to control the blood flow to
the heart.
 Percutaneous coronary intervention(angioplasty)
 Coronary artery bypass graft(CABG).
 Rehabilitation
Thought question
• In coronary heart disease patients , you prefer
the resistance exercise, or moderate rhythmic
aerobic exercise during rehabilitation program
and why?
Management
Treatment of coronary artery disease includes addressing "modifiable"
risk factors. This includes
• Suppression of cholesterol
• Control of blood pressure,
• Control of blood sugars (if diabetic),
• Regular exercise
alters blood fat levels by increase HDL
• A healthy diet.
 increasing viscous (soluble) fiber intake which slows the rate at
which food is broken down and nutrients like glucose are
absorbed so it decreased risk of high blood cholesterol and
diabetes.
 decreasing saturated & trans fat intake
• Stop smoking
Cont.
The role of physical therapy in MI , at the first
48 hours:
To prevent the accumulation of secretions in
the lung which may predispose to chest
infection and complications
Prevent stasis in the deep veins of the legs
Improve the ventilation.
Quiz.
• Sami is 56 years old and considers himself to be in good health. He
has a family history of heart disease, stroke, and diabetes. He
recently had a routine physical exam. He was told that his blood
pressure was 130/85, his total cholesterol was 210 (LDL was 175
and HDL was 35), and his glucose levels were normal. He was also
informed that his weight of 190 pounds made him about
10pounds overweight.
Sami's physician expressed some concern about the results of the
exam. What finding is most likely the key cause of her concern?
A. high cholesterol levels
B. high blood pressure
C. high weight
D. high age
THANK YOU