Professional Documents
Culture Documents
Pendrik Tandean
Division Cardiology of Internal Medicine
Department
And
Cardiology Department, Medical Faculty of
Hasanuddin University, Makassar
5/98
Worldwide Statistics
Each year:
> 4 million patients are admitted
with unstable angina and acute MI
> 900,000 patients undergo PTCA
with or without stent
Modifiable :
- Smoking
- Dyslipidemia (Raised LDL-C, Low
HDL-C, Raised triglycerides)
- Raised Blood pressure
- Diabetes melitus
- Obesity
Non-Modifiable :
- Personal History of CVD
- Family History of CVD
- Age
- Gender
Family History
Premature CHD
Men (first degree) < 55 years.
Women (first degree) <65 years.
Supply = Demand
Myocardial ischaemia
Ischemic heart disease
Clinical Manifestation
Stable angina
pectoris
ST elevation:
NO
Non ST elevation
myocardial infarction
Unstable angina
Conduction
disturbances
Sudden death
ST elevation:
YES
Myocardial infarction
Myocardial infarction (Q)
(non Q)
Clinical assesment
Laboratory test
Specific cardiac investigations
History
Physical examination
For Diagnosis
For Prognosis
Class of
Indication
Level of
Evidence
Class of
Indication
Level of
Evidence
Fasting glucose
IIb
IIb
Initial evaluation
IIb
IIb
Laboratory tests
Test
For Diagnosis
Class of
Indication
Level of
Evidence
IIa
IIa
For Prognosis
Class of
Indication
Level of
Evidence
Test
Echocardiogram
Suspected heart failure, abnormal
auscultation, abnormal ECG, Q waves,
BBB, marked ST changes
Previous MI
Hypertension or Diabetes Mellitus
Intermediate or low risk patient not due to
have alternative assessment of LV function
For Diagnosis
For Prognosis
Class of
Indication
Level of
Evidence
Class of
Indication
Level of
Evidence
B/C
IIa
Test
Exercise ECG
First line for initial evaluation, unless unable
to exercise/ECG not evaluable
Patients with known CAD and significant
deterioration in symptoms
Routine periodic testing once angina
controlled
For Diagnosis
For Prognosis
Class of
Indication
Level of
Evidence
Class of
Indication
Level of
Evidence
IIb
IIb
Test
Exercise imaging technique
(echo or radionuclide)
Initial evaluation in patients with
uninterpretable ECG
Patients with non-conclusive exercise test
(but adequate exercise tolerance)
For Angina post revascularization
To identify location of ischaemia in planning
revascularization
Assesment of functional severity of
intermediate lesions on arteriography
For Diagnosis
For Prognosis
Class of
Indication
Level of
Evidence
Class of
Indication
Level of
Evidence
IIa
IIa
IIa
IIa
Test
Pharmacological stress imaging
technique
Patients unable to exercise
Patients with non-conclusive exercise test
due to poor exercise tolerance
To evaluate myocardial viability
Other indications as for exercise imaging
where local facilities favour
pharmacological rather than exercise stress
Non-invasive CT arteriography
Patients with low probability of disease and
non-conclusive or positive stress test
For Diagnosis
For Prognosis
Class of
Indication
Level of
Evidence
Class of
Indication
Level of
Evidence
IIa
IIa
IIa
IIb
TREATMENT
Aims of treatment.
A. Improve prognosis by
preventing myocardial infarction
and death
B. Minimize or abolish symptoms.
Non-pharmacological
Non-Pharmalogical
Non-Pharmacological
Pharmacological therapy
Pharmacological therapy
Pharmacological therapy
PATOGENESIS
Unstable Plaque
Occlusive Thrombus
No ST-segment
elevation
Unstable
angina
History
Physical Exam
ST-segment
elevation
Non-Q
AMI
Q-Wave
AMI
ECG
Acute
Reperfusion
Unstable Angina
CANADIAN CARDIOVASCULAR
SOCIETY FUNCTIONAL
CLASSIFICATION
Clinical Features of MI
Determining/confirming an
MI
Serial EKGs
Angina
T wave inversion
ST depression
Conduction defects (eg-bundle branch blocks)
MI
ST depression
T wave inversion
Presence of Q wave
Elevated ST segment
Cardiac enzymes
Electrocardiogram
ST segment Elevation
http://www.emedu.org/
ST segment Elevation
http://www.emedu.org/
ST SEGMENT ELEVATION
ST segment depression
http://www.emedu.org/
Cardiac Biomarkers
Troponin T and I
50
Myoglobin
20
Cardiac Troponin
CK-MB
10
Echocardiography
Nuclear scans
Technetium pyrophosphate
Thallium scans
Echocardiography
Coronary Angiography
Dadkhah
THANK YOU