Cardiovascular System >
Ischaemic Heart Disease

“Coronary Heart Disease (CHD) from lack of blood supply & cell death”

Risk Factors
  • Modifiable:
    • Smoking
    • Obesity
    • Physical inactivity
    • Hypertension,
    • Diabetes mellitus
    • Hyperlipidaemia (modifiable because with proper control IHD can be prevented)
  • Non-Modifiable:
    • Sex (male)
    • Advancing age
    • Family history of IHD (MI in 1st degree relative < 55 years)
Aetiology
  • Lack of sufficient blood supply leading to lack of oxygen (ischaemia) with possible cell death → angina and myocardial infarctions
Pathophysiology
  • Atherosclerotic plaques on the walls of the arteries narrowing the lumen → imbalance between supply and demand → ↓ blood flow → myocardial hypoxia and accumulation of waste metabolites
Clinical Presentation
  • Stable Angina:
    • Central chest pain coming on exertion and alleviated by rest and GTN spray; occurs after walking predictable distances
  • Unstable Angina:
    • Pain occurring with increasing frequency
    • Unpredictability, at minimal exertion, or at rest
  • Myocardial Infarction
    • Acute crushing central chest pain lasting > 20 minutes
    • May radiate down the left arm
    • Nausea
    • Sweatiness
    • Dyspnoea
    • Palpitations
Investigations
  • Bloods:
    • FBC, U&E, glucose, lipids
    • Cardiac enzymes – Troponin- significantly elevated in STEMI, elevated in NSTEMI, and normal in unstable angina
  • Imaging:
    • Chest X-Ray – cardiomegaly, widened mediastinum
  • Special:
    • ECG
      • In STEMI – hyperacute (tall) T waves and ST elevation within a few hours, T-wave inversion and pathological Q waves follow over hours-days
      • In NSTEMI / Unstable angina – ST depression, T wave inversion
Management
  • Conservative Interventions:
    • Stop Smoking
    • Cardioprotective diet
    • Increase physical activity
    • Weightloss
    • keep alcohol consumption within recommended limits
  • Immediate interventions for STEMI:
    • Aspirin 300mg; IV morphine; high-flow oxygen; angiography and primary PCI <120 minutes or fibrinolysis <12 hours; anticoagulant until discharge (fondaparinux)
  • Immediate interventions for NSTEMI and unstable angina:
    • Aspirin 300mg; second antiplatelet therapy (clopidogrel 300mg); anticoagulation until discharge (fondaparinux); nitrates (GTN) for pain; oral β-blocker (bisoprolol) but if contraindicated use CCB (verapamil)
  • Angina:
    • Sublingual glyceryl trinitrate (GTN); aspirin 75mg; β-blocker (bisoprolol, metoprolol, propranolol) or a CCB (verapamil, diltiazem); if CCB or β-blocker not tolerated, consider monotherapy with one of the following: nicorandil, ivabradine, or a long-acting nitrate (isosorbide mononitrate)
  • Myocardial Infarction:
    • ACEi (ramipril); angiotensin receptor blocker (ARB) if ACEi is not tolerated (candesartan, losartan); aspirin 75mg; antiplatelet drugs (ADP-receptor antagonists: clopidogrel, ticagrelor); β-blocker (bisoprolol, metoprolol, carvedilol, atenolol, propranolol); statin (simvastatin, atorvastatin
Complications
  • Stroke
  • Heart Failure
  • Consecutive cases of IHD
  • Depression
  • Anxiety disorders

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