Transcript Yes (+1)
ISCHMIC HEART DISEASE PRESENTATION DR . OMAR ALKASEM Natural History of CAD : A story of remodeling 7 Heart - Pathology Heart - Pathology Ischemic Heart Disease 75% stenosis = symptomatic ischemia induced by exercise 90% stenosis = symptomatic even at rest Pathogenesis ↓ coronary perfusion relative to myocardial demand Role of Acute Plaque Change (Erosion/ulceration, Hemorrhage into the atheroma, Rupture/fissuring, Thrombosis) Role of Inflammation T cell, Macrophages (MMPs), CRP Role of Coronary Thrombus The most dreaded complication Role of Vasoconstriction (VC) Platelet & Endothelial factors, VC substances Cardiovascular Disease Risk Factors History of CAD/PAD Male Sex History of TIA/CVA Smoking Hypertension Diabetes Mellitus Dyslipidemia Low HDL < 40 Elevated LDL / TG Family History - event in first degree relative > 55 male, > 65 female Chronic Kidney Disease Obesity Lack of regular physical activity Diet poor in fruits, vegetables, and fiber Age > 45 male, > 55 female Western Lifestyle Smoking, Framingham Most Significant Milestones 1960 Cigarette smoking found to increase the risk of heart disease 1961 Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease 1967 Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart disease 1970 High blood pressure found to increase the risk of stroke 1976 Menopause found to increase the risk of heart disease 1978 Psychosocial factors found to affect heart disease 1988 High levels of HDL cholesterol found to reduce risk of death 1994 Enlarged left ventricle (one of two lower chambers of the heart) shown to increase the risk of stroke 1996 Progression from hypertension to heart failure described Ischemic Cascade Angina Δ ECG Stress ECG Systolic Dysfunction Stress Echo/MRI Diastolic Dysfunction Perfusion Abnormalities Nuclear Imaging Duration and severity of ischemia Heart - Pathology Ischemic Heart Disease Classification = mainly 4 types Angina pectoris Acute Coronary syndromes Sudden cardiac death Chronic IHD with heart failure Angina Pectoris At least 70% occlusion of coronary artery resulting in pain. What kind of pain? Chest pain Radiating pain 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 21 when exertion is ceased Spectrum of ACS Presentations UA Definition Ischemia without necrosis Negative Biomarkers NSTEMI STEMI Necrosis (nontransmural) Transmural necrosis Positive biomarkers Positive biomarkers Diagnosis No ECG ST-segment elevation Treatment Invasive or conservative depending on risk ECG ST-segment elevation Immediate reperfusion 58 yo Man, Chest pain after lunch on the way to car. Bad sushi? Physical Examination Not helpful in distinguishing pts with ACS from those with non cardiac etiologies Pts may appear deceptively will without distress or be uncomfortable, pale, cyanotic, and in respiratory distress. Vital Signs Bradycardic rhythms are more common with inferior wall MI in the setting of anterior wall MI, bradycardia or heart block is very poor prognostic sign Extremes of blood pressures are associated with worse prognosis Heart Sounds S1 and S2 are often diminished due to poor myocardial contractility S3 is present in 15-20% of pts with AMI implies a failing myocardium S4 is common in pts with long standing HTN or myocardial dysfunction Presence of new systolic murmur is an ominous sign signifies papillary m. dysfunction, flail leaflet of mitral valve, or VSD Differential Dx for ACS Chest Pain Syndromes (beyond STEMI, NSTEMI, UA) Aortic dissection Pulmonary embolus Perforating ulcer Pericarditis GERD (Gastroesophageal reflux disease) Heart failure, Pneumonia, Pneumothorax Example of ST-segment Elevation (STEMI) J point STE Example of ST-segment Depression (UA/STEMI) STD J point Normal 12-lead ECG LATERAL ANTERIOR LATERAL INFERIOR http://www.uptodate.com/contents/image?imageKey=CARD%2F1617. Accessed Aug 6. 2011. Early-Stage Acute MI (STEMI) ST-segment elevation T-wave inversion ST-segment depression UA - NSTEMI T-wave inversion 48 yo M, HBP with Chest pain while walking ECG ST segment is elevated on the initial ECG in approximately 50% of pts with AMI most other AMI pts will have ST depression and/or T wave inversions Only 1-5% of pts with AMI have an entirely normal initial ECG Difficult ECG interpretations ST elevation in absence of AMI early repolarization LVH pericarditis/myocarditis Left ventricular aneurysm Hypertropic cardiomyopathy hypothermia ventricular paced rhythms LBBB Cardiac Enzymes Serial measurements are more sensitive and accurate than initial single measurement serum markers have less utility in the diagnosis of UA, only about 50% will have elevated troponins Timing of Release of Various Biomarkers After Acute Myocardial Infarction Cardiac-specific troponins are optimum biomarkers (Level IC) For STEMI, reperfusion therapy should be initiated as soon as possible and is not contingent on a biomarker assay (Level IC) TIMI Risk Score (n=7) TIMI Risk Score Calculator Age ≥65 years? Yes (+1) ≥3 Risk Factors for CAD? Yes (+1) Known CAD (stenosis ≥50%)? Yes (+1) ASA Use in Past 7d Yes (+1) Severe angina (≥2 episodes w/in 24 hrs)? Yes (+1) ST changes ≥0.5 mm? Yes (+1) + Cardiac Marker? Yes (+1) Total Score pts What does TIMI RISK mean? Increasing TIMI RISK 0/1 to 5/7 increases risk of death, MI, urgent revascularization within 14 days 5% to 41%. Treatment of Acute Coronary Syndrome Early Invasive Initial Conservative Cardiovascular Diet