ISCHEMIC

 HEART  DISEASE/  CORONARY  ARTERY  DISEASE    

IHD/CAD  is  a  condition  in  which  there  is  inadequate  supply  and  demand  of  blood  and  
oxygen  to  a  portion  of  the  myocardium
IHD/CAD  can  be  presented  as:
• Chronic  coronary  artery  disease  (CCAD):  Stable  angina  
• Acute  Coronary  Syndromes  (ACS)  
o Non  ST-­‐segment  Elevation  (NSTEACS)  
§ Unstable  angina    
§ NSTEMI  
o ST-­‐segment  elevation  myocardial  infarction  (STEMI)  
• Others:  asymptomatic  (  DM,HTN,  elderly,  females)  
CCAD ACS
Stable Angina NSTEACS STEMI
Unstable Angina NSTEMI
Pathophysio Stable fixed Sudden plaque rupture> Sudden plaque rupture> Sudden plaque rupture>
atherosclerotic plaque partial occlusion partial platelet+partial partial platelet+complete
(platelet aggregation) thrombus occlucion acclusive thrombus
-Rest angina
-New onset
-Post infarct angina
-Post coronary
procedure angina

Characteristics Heavy, Tightness, Aching, Burning Heavy, crushing, burning

Sites Deep retrosternal Deep retrosternal
Radiation Lower jaw, neck, arm(left 20x common), epigastrium, interscapular and back
Relieving & A-With exertion Occur at rest
aggravating R- Rest & Not relieved by nitroglycerine
nitroglycerine
Duration Avg 3-5 mins > 15-20 mins
Associated Strangling in throat Pallor, nause, vomiting, sweating, dyspnea, syncope
symptoms
PE S3 during attack Cold, clammy, muffled heart sound, gallop rhythm,
systolic murmur (MVP), basal crackles
ECG Normal Low risk: Normal NSTEMI: ST depression, no Q waves,T wave
High risk: ST inversion
depression, T wave STEMI: +/- Deep Qwaves, T wave inversion, ST
inversion or tall upright elevation. Associated with LBBB/WPW/ Ven Tach
T waves
Cardiac Enzymes - -Troponin I/T: Non -Troponin I/T: Detectable
*Sequence of detectable in low risk, -CK: Elevated
elevated detectable in high risk
biomarkers- Trop- -CK: normal
T,CKMB,AST,LDH
*CKMB- useful for
reinfarction MI
*Troponin I most
specific

Special definitive ECG ECG

dx test Coronary angiography (strong +ve stress exercise Cardiac enzymes
ECG, resistant to medical treatement, angina after Technetium pyrophosphate scanning (posterolateral
MI, suspected angina, suspected left main AMI_
coronary artery disease) Echo (early stage MI/other test not diagnose)
Coronary angiography

Management -Medical First line (Outside hospital)

*acute attack - Perform ECG; clasify ACS
#Nitroglycerine/ -Oxygen 4-6L/min
nifedipine-CCB -Secure IV line (draw blood for cardiac enzyme)
#Aspirin -Nitroglycerine (every 5 min- take ½ intially, maximum 3 tab in 15 mins)
*Mild (predictable -Aspirin
with stressful -Morphine (IV statim bolus; 1mg/min until pain relief up to 15mg)
activities)
#Nitroglycerin * Re-establish flow *Re-establish flow
#Aspirin/ clopidogrel -PCI /Angioplasty with stent ( thrombolytic -Thrombolytic
#consider Beta theraphy not benefit) theraphy; door to
blocker/ long acting -CABG needly time <30 min
nitrate/ nicorandil *other same as STEMI -PCI /Angioplasty;
*Moderate #complications of angiopplasty door to balloon time
(predictable with -acute coronary occlusion <90min; >12 hours not
moderate exercise) -restenosis recommended
# add beta blocker -CABG
*Persistent (not #Stent patients require long term antiplatelet
prevented by beta (aspirin+clopidogrel) *Adjunct theraphy
blocker) -aspirin/ clopidogrel
#add dihydropyridine -heparin for 24-36 h
CCB #Indications for CABG:
• Over 50% left main coronary artery stenosis after rt-PA(not after
-Non-medical streptokinase)
*PCI/Angioplasty • Over 70% stenosis of the proximal left - +/- glycoprotein
with stent anterior descending (LAD) and proximal IIb/IIIa platelet
*CABG circumflex arteries inhibitor
• Three-vessel disease in asymptomatic patients
or those with mild or stable angina *Beta blocker + ACE
• Three-vessel disease with proximal LAD inhibitor
*Statin
stenosis in patients with poor left ventricular
(LV) function
• One- or two-Vessel disease and a large area of
viable myocardium in high-risk area in
patients with stable angina
• Over 70% proximal LAD stenosis with either
an ejection fraction (EF) below 50% or
demonstrable ischemia on noninvasive testing
Others Causes of angina: Types: Complications
Coronary artery -Nocturnal angina STEMI:
atheroma -Decubitus angina: occurs 0-24 hours
Valvular lesions when lying down, relieved by -Acute LV failure
Arrhythmia sitting up -Cardiogenic shock
Anemia -Variant/ Prinzmental angina- -Arrhythmia
Vasculitis due to coronary artery spasm
Trauma 1-3 days
Collagen disease -Pericarditis

3-14 days
-Venticuar septal
rupture & Mitral valve
papillary rupture

2 weeks-several month
-Post-AMI syndrome
(Dresler syndrome)
-LV aneurysm

Aqilah Mazlan