Ischemic Heart Disease

Posted on Aug 5, 2024 in Medicine & Health

**AP :


^^Etiology+RISK
^^AP + ischemia:
^^Blood Supply to the Myocardium:
^^Myo O2 Demand:
1. Myo O2 >  oxygen
supply
2. Cellular acidosis & lactate release
3. ST ↓ on ECG
→ ST ↓ in the absence of angina is called=silent ischemia.
!!! Angina = Ischemia

• CA, A stenosis
→ Stable angina if > 70% lumen obliteration
• CA spasm
(endothelial dysfunction)
• Hcoagulation states
• An
•l ↑,HR↓ HR
• myocardial hypertrophy

 Physical / emotional exertion
• ↑HR
• Myo hypertrophy
^^Modifiable 1st Line Risk Factors:
^^Unmodifiable Risk Factors:
^^Normal Lipid Profile:
• Dyslipidemia
• Hyperfibrinogenemia
• Smoking
• Arterial hypertension
• Diabetes mellitus
• Familial predisposition
• ↑ Age
• Male sex

Total cholesterol:
LDL cholesterol:
HDL cholesterol: > 1.0 mmol/L
Triglycerides:


^^CF:

-Pain Sensation of pressure, squeezing, burning,
or numbness
When? : physical, emotional stress, cold
• Where? :Sub- or parasternal area, epigastric
• Radiation? Neck, shoulder, arm (mostly left)
• How long?  0.5 – 15 min
• Relief? 1.5 – 3 min after sublingual nitroglycerin
• Levine’s Sign: patient shows pain with palm

-• Dyspnea/ Nausea/ Anxiety/ Cold sweating^^Classification:

^Class O Asx ^Class I Strenous Excersion L-Prlonged Excercion-Strenous Exc^Class II Mode Excerion:-High but Daily Activity-More Frequent attack
Class III Mild Excertion:-Moderate physical activity (+) AP(wal 100 m)Class IV -At Rest:AP  Light Physical activity or rest




^^Dx:

I- CF:
I-ECG: 
IV-Echocardiography:asses:
V-PErfusion scitigraphy with Thallium 21
• Pallor
• ↑ heart rate
• ↑ blood pressure
• Gallop rhythm
• Paradoxical S2
• Paradoxical movement

-may be N ( 50% of pts) at rest-Needs continous recording-ST ↓ or ↑ / T Invertion/ R ↓ 
Cardiac muscle-Size of Cavities-S+D function of LV-total Segment function of LV
VI-Interventional studies:-Coronary atery Angioscopy-Intracoronary echography:VII – Stress Test  VIII -ECG 24 H


^^^Tx:
^^GOALS:-alleviate /prevent Anginal Pain-↑ Quality of Life-Fast Dx of MI and prevent ischmia death
^^ Lifestyle changes:
• Improve nutrition
• ↓ body weight
• ↑ physical activity
• ↓ blood pressure
• Modify modif risk factors

^^ ↑ Oxygen Supply:
• Nitrates
• ACE-I
• Revascularization procedures:
Percutaneous coronary intervention
Coronary bypass operation

^^↓ Oxygen Demand:
• Nitrates
• β-blockers
• CCB
• Ivabradin
• Ranolazine


I-Nitrates
III-B blocker:
IV-Ca channel blocker

-↓ :Systolic BP, Myocardiac Wall Extension)-↑:Cardiac contractility)(Blood from non ishcmia to ismia zone)sublingual nitroglycerine -.5mg 
II-Long acting Nitrates:
Block (S) Stimulation of Heart-↓ Systolic BP/HR/Contractility/CO-non selective( B1+B2 Rec)- Proponolol timololmpinlolol-Cardioselective(Only B2)-Metoporlol , Atenolol,Betaxolol)-Long term Tx :Cardioselevtive

-(+) Hemodyanimic effect:-↑ DS & S function -↓  hypertrophy of LV+ BV-(Dihydrourdines/ Branzodiazepine)








****NSTEMI :


^^CF:-Angina >20 min-Deep ,substernal Pain-Aching pressure -radiating back /JAw-nitroglycerin 0-Pain can start @ night 4Am  with↑ severity-NSTEMI =subenchocardial only part of ventricle
^^Dx

PE:
I-ECG is most imp 
II-Biomarkers:
HBP or hBO
• HR ↑, or HR↓
• Gallop rhythm,
-systolic murmur
• Pul edema

– 10 min from admissiton-ST changes-LBBB
-(myoglovin /TOTAL CK / CM-MB/ troponin T+ I)-elevate 5 x the N—–> imediate invasive management
III-Xray:
IV-Echocardiography:

-pul edema-Heart Dialation
-Regional wall motion defect-asses LVV-Perufsion scitongtaphy (Thallium 201)


^^Risk Assesement:

GRACETIME
-Age
– BP, HR
•↑, cardiac biomarkers
-l↑,serum creatinine
• Killip class at presentation
• Cardiac arrest on admission
• ST changes
•  65 (+) YO
• > 3 CAD risk factors
• Known CAD
• Aspirin use 7 days
• Severe angina (> 2 episodes/24 hours)
• ST changes
-positive cardiac marker


^^TX:
Strategies:
– ↓ myocardial O2 demand
(Nitrates, β-blockers, ACE-I)

– Reocclusion prophylaxis

(Antiplatelets, anticoagulants)
– Atherplaque stabilization(Statins)
First Aid: MONA rule
Pharmacological Treatment Sequence:
New Antiplatelet Drugs:

Morphine 3 – 5 mg i/v
Oxygen 4 – 8 L/min
Nitrates i/v
Aspirin 150 – 300 mg

1. β-blockers (metoprolol 25, 50, 100 mg)
2. ACE-I (ramipril 2.5, 5, 10 mg)
3. Nitrates (ISMN 10, 20, 40, 60 mg)
4. Statins (atorvastatin 10, 20, 40, 80 mg)
5. Antiplatelet (aspirin 75 – 150 mg, clopidogrel 75)
• Ticagrelor 90 mg 2x/day
• Prasugrel 10 mg daily
• Clopidogrel 75 mg daily

 Invasive coronary Angiography ind:

VHigh Risk PCI H RiskPCIM riskPCI
• Hemodynamically unstable
• Life-threatening arrhythmias
• Mechanical complications

• Rise of fall in troponin
• Dynamic ST changes
• Diabetes mellitus
• Renal insufficiency
• LVEF

^^Long Term:

• Life style changes
• Initiate high-intensity statin therapy
• Antihypertensive therapy

• Dual antiplatelet therapy
• ACE-I in LV dysfunction, hypertension, diabetes
• β-blockers if LVEF




***MI^^Troponin T and I :

– highly-specific to myocardialtissue.
-essential biomarkers to
diagnose MI.
• (S) 80% after 3 hours
• (S) 100% after 5 hours
• Max after 12 hours

Causes of ↑ Troponin:
•MI
• M-tis
• Hypertensive crisis
•A stenosis
• Kidney(-)
• ↑ ↑ physical activity



^^Complication :

Early Complications:
Late Complications: > 48 hours
• aRR
Ventricular extrasystoles
Ventricular fibrillation
/flutter
Atrial fibrillation
Bradyarrythmias
• LV insufficiency & cardiogenic shock
if > 20% of LV MI
• RV insufficiency
Cardiac aneurysm
• Arterial embolisms
• Pericarditis
• Dressler syndrome
• Arrhythmias
• Heart failure


***STEMI-Aspirin 325 mg-Cardiac monitory , Oxumtery-O2 is given for first few hours-Morphine 5-10 mg IV-Nitrglycerin-Thrombolysis or PCIInd : typical pain . ECG ST elevation >1mm , new LBBB)(Contra ind :internal bleeding /pacreatitic/ stroke/ trauma)(Regiment: IV streptroinase (2/5 firline agent)(Anistreprase )(Reteplase)

-B-Blockers:
-ACE (-):
-Antithromboptic Drugs
^^ subsequent Tx:
(antagonist hyperadneric State),( ↓ HR, BP, O2 demand)(IV metaprolol 5mg over 2 min ,repeat 5 mins 15mg till hR
(GOALS: AVild geometric ventricle change / (-) dialation of cavivties/ ↓ infaction& mortality)(Ind : Q wave in MI / ↑ the VC)(X :Captropril/enalpril)
(OP : aspirin/ Clopidogei)
(Heparin : unfractionEnocparin )
(GP IIB, IIIa(-) : Ableximab)
-Bed rest(1 recumbecy ,2 sitting 2 hours 5 WC walking 7-9 discharge)-Aspirin)-Long term B blocker)-Statins( simvastin 40 m


^^ Medication :

I-Antiplatelet 
II- antithrombotic Agnent:
(OP Aspirin/ clopodrogen)(IV antiplatlent : glycoprotien IIb/IIIa)
( Undefraction heparin(LMWH)

^^CABG

^^CABG
^^Percutanous coronary intervation
(Ballooon Angioplasty)(Stent placement)(Atherectomy)(Radiation)

^^ Principle:-Track Sx of angina pectoris-↑ Long term suribal– ↓ nonfaal events , Congestive HF , Ventricular arrythmia-unstable angina-The surgical revascularization done in cases > 50% stenosis of the left coronary artery stem,

-> 70% stenosis of proximal segments of 2 – 3 coronary arteries, drug-resistantAP, & in cases of ↑ LVF

***HPB :^^^ Classification:

* And/orS DS
optimal
N120-12880-84
High N130-13985-89
Hypertonia 1140-15990-99
Hypertonia 2150-179100-109
Hypertonia 3>180>110
Isolated( S) >140

^^^RISK :



Hereditary
• Excessive Na+ intake
• OH abuse
• Age  35 (+)
• Smoking
• Physical inactivity
• ↑ BMI
• ↑ Blood cholesterol
Chronic stress
• Drug intake:
Adrenomimetics
Oral contraceptives
NSAIDs
Glucocorticoids
Tricyclic antidepressants
Amphetamines
→ Probability to develop cardiac or cerebral complications of hypertonia
Normal 30%
^^^TX
^^Gx:
Diet → ↓ weight
• Sufficient exercise
• Stop smoking and drinking
• ↓ stress
^^X:
 Never use a combination of drugs that act on the
same site.
• Diuretics → ↓BV
• α-blockers, β-blockers → ↓ renin secretion
• ACE-I, AGT2RI → ↓ vascular tone
• CCBs → SMC relaxation
• Centrally acting antihypertensives (clonidin)
• Vasodilators (hydralazine)

***Rh Fever^^^Criteria:”Jones Criteria”:-Evidence of Preceding GAS infection (GAS= Group A streptococcal Infection )( ↑ Antistrepto Ab) ,+ Throat culture )

^^Major
-Caridtis-Chorea-erythmea marginatum-polyarthritis-Subcutanous nodules
^^Minor
-arthralgia  ↑ ESR/ CRPFever↑ ASO
Prolonger PR intervalStrep A infection
Dx:
(↑ Antistreptoccocal Ab)+ hroato Culture (+) + (2 Major)
….. + (1major)+ (2 minor)
^^^^Tx+Prevention:
Acute PhaseLate Phase
Bed 2-6W-Pen G 10 days-Allergy (cephalosprin /erythromycin)-NSAID forarthalgia(aspirin)-Prednisone  in HFuntil CPR is N-Diazepan for Chorea
-AV /MV surgery
-Bioprothesis if no anC-Biventricular pacing in HF
^^Prevention
PrimarySecondary
-Accurate Dx-Tx for Strepto infDuration of 2nd Ax prevention:RF+ Cariditis& Residual valve disease—>10 until40 YORF+carditis and no valvedisease—>10  till 21 YORF with No carditis—>5 Years until 21 YO
-Prevent reoccurenace-Continuos X:1-Pen G/V2-Sulfadiazine3-Macrolide-Strepto vaccine-Tx of inflamm Foci
Duration of 2nd Ax prevention:RF+ Cariditis& Residual valve disease—>10 until40 YORF+carditis and no valvedisease—>10  till 21 YORF with No carditis—>5 Years until 21 YO***MR:^^Etiology :
Primary(Valvular)Secondary( Functional)-Acute: IE/acute MI/ chordial papilal rupture-Chronic : degenerative changes-Dilative CMP-LV and annulus dialation^^Px:1-(S) Reversl BF from LV to LA2-LA overload–> LA dilation & hypertrophy3-↑ LV preload—>LV pressure&vulume ↑—>LV dialation& hypertrophy4-Pul Venus congestion—Pul Artery HBP5-↑ RV afterload—->RV hypertrophy
DxTX^^Sx:-slow excertional Dyspnea-Weaknss & Fatigue-Palpitation^^Sign:-Fatigue-Exertional dyspnea-atpical AP-palpitation^^ECG:(nonspecific)-P Mitral-A Fib^^Xray:-LA + LV  ↑-Pul venous congestion^^Echo:(GOLD standard)-Quantification-Chamber dimension-EF^^CT:-Thoracic aorta evaluation^^MRI:if Echo was insuff^^X:-Asx and No LVH: no Tx-Sx and EF-Pul Congestion:(Diuretic)
-Sx :↓ Afterload—>ACEI+AG2-1-Rhythm Control:(CCB,B blocker, Digoxin)^^Ind for Surgery:-SX patient-Asx with EFPul HBP ,A Fib-Acute / Chronic ischmia MR-Rupture & papilla muscle-Significant coronary stenosis^^MV reconstruction:↓ perioperative mortality
 ↑ prognosis
^^Mitral Valve Replacement: Ultima Ratio!
***MS:^^Def: narrowing of MV opening blocking blood from LA to LV!^^Etiology:-Rh Fever 95%-Congenita-Annulus Calcification-SLE-Myoxoma-RA^^Px:1-MV gets smaller     er from 4-6 cm2 ——–>2cm2)2-less blood From LA to LV)3-↑ AV  pressure gradient
4- LA pressure overload → LA dilatation & H-trophy
5- ↑ pulmonary venous pressure → pul  blood congestion
6- Pul  artery HBP → ↑ RV afterload → RV dilatation and hypertrophy
7- Systemic blood congestion
Dx:
Tx:
^^Sx:-excertional dyspnea-hemotpysis-Chest pain-C bronchitis-Facies Mitralis^^Ausculation:-S1 ↑S2 split &  ↑DS murmor ↓-ProtoDS thrillat apex^^ ECG:-P mitrale-A Fib-RVH^^Xray:-mitral Configuration ofheart-LA  ↑– ↑ of Pul artery ,RV,RA^^Echo:(GOLDEN)MV calcification–>↓ MVLA  ↑RV  ↑LV N Leaflet excurcion  ↓^^ECG stress test:-Worse Sx-↓ physical capacity^^Coronary Angiography:Preoperative
^^X:-Pul Congestion:(Diuretics)-Rhythm Control:(Digoxin / B Blocker/ CCD)-anC:(Vit K , Anatagonist,warfarin)^^ Ind for surgery:-Sx Patient with Meds^^Open Surgery;MV replacemet-Open commissurotomy^^Percutanous Mitral Baloon valvuplasty:Young patient^^Percutanous Mitral COmmussurotomy:CI : LA thrombus ,severe calcification
Pressure GradientMVN4.0-6.0Mild5-81.5-2.0Mod8-151-1.5Severe>15

***AR^^Def:-Incompetnecy of Aortic Vavle ,– Permanent DS Blood reflux from Aorta into the LV^^Etiology :
PrimarySecondary-Congenital Bicuspid(unicuspid)-Rh Fever-Inf Endocarditis-Degenerative Change-Art HBP-Aortic aneurysm-Morbus Bechterew-Marfan Sx-Aortoannular ectasia-Syphilus
^^Px:1-During S aorta dilate, during DS it contracts!2-(DS) reverse BF from aorta to LV3- LV volume& pressure overload—-> LV eccentric Hpertrophy4-↑ LV end-diastolic pressure5-Coronary artery Hypoperfusion6-Relative MV (-)—–>↑ LV filling7-↑ pul venous pressure—pul blood congestion***AR^^Def:-Incompetnecy of Aortic Vavle ,– Permanent DS Blood reflux from Aorta into the LV^^Etiology :
PrimarySecondary-Congenital Bicuspid(unicuspid)-Rh Fever-Inf Endocarditis-Degenerative Change-Art HBP-Aortic aneurysm-Morbus Bechterew-Marfan Sx-Aortoannular ectasia-Syphilus
^^Px:1-During S aorta dilate, during DS it contracts!2-(DS) reverse BF from aorta to LV3- LV volume& pressure overload—-> LV eccentric Hpertrophy4-↑ LV end-diastolic pressure5-Coronary artery Hypoperfusion6-Relative MV (-)—–>↑ LV filling7-↑ pul venous pressure—pul blood congestion^^^TxI-X:-Vasodilators (ACE-I, CCB) → ↓ afterload
– β-blockers → prevent aortic rupture
– Avoid bradycardia → No β-blockers in severe AR
– IE prophylaxis in high risk patients 
II-ind for surgery:-Sx Patient-Asx Patient(EF(>5%EF ↓)
ECG-stress-test, LV end-diastolic diameter > 75
mm, OR LV end-systolic diameter > 55 mmEF ^^Aortic Valve Replacement:
• Frequently aortic root esection requirred

***AS^^Def: Narrowing of Aortic Valve Producing Obstruction of BF from LV  to ascending aorta during Systole^^Etiology :

Congenital Acquired
• Bicuspid
• Unicuspid
• Quadricuspid
Calcification , 65 years(+)
• Rheumatic (40 – 60 years)
• Disturbances of Ca2+ metabolism
• Rh arthritis
• Renal (-)
• Fabry disease

^^Px:1. ↑ LV (S)  & (DS) pressure → Prolonged ejection time
2. LV pressure overload → LV concentric hypertrophy
3. ↑ myo O2 consumption → ↓ relative myol perfusion
4. LV myocardial ischemia → LV myo  fibrosis
5. ↑ LV filling pressure → ↑ pul venous pressure → Pulmonary blood congestion
***Tx

^^Dx:
Tx:
^^Sx:-AP-Sncope-Exertional dyspnea^^ PE:-small weak late peaking carotid Pulse-(S) throll^^Ausculation :-(S) Thrill aortic Areas-↓S2 ,S4 in severe cases-Crescendo -decreasendo Systolic Murmour^^ ECG:-LVH+ pressure overload-LBBB^^ Xray:-Aortic Configuration-Aortic arch Calcinosis-Postentonitc dilation-Pul congestion^^Echocardiography:(Golden)-↑ Flow velocity through AV>2.5m/s-Quantification of AS-concentric LVH^^palpation:pulsus parvus et tardus^^Coronary angiigraphy:CHD at risk
^^General Approach:-Correct CAD Risk Factors-↓Physical activity in severe AS^^X:-No effective Tx-Low Dose Diuretics(↓afterload)-Low Dose B blocker^^Indication for Surgery:-Sx patients with moderate/severe AS-Asx with moderate severe AS + Heart surgery-Asx patient+ severeAS+EF^^Balloon vavloplasty:-temperal effect-Dialation of Aortic Orfice-Restenosis 6-12 Month^^Aortic Valve Replacement:-Open surgery-patient with low risk^^Transcatheter aortic valveimplantation(TAVI):-patient with moderate or high operative risk


****ASD

^^^Px:

Classifciatin:
• Ostium primum 20%
• Ostium secundum 70%
• Sinus venosus
• Coronary sinus
• Open Foramen ovale


• Right heart dilatation and failure
• Atrial arrhythmias
• Pulmonary hypertension → Dyspnea
• Stroke
• Recurrent respiratory infection

^^^DX:

I-Sx:

> 5 mm:
• Palpitations
• Exertional dyspnea
• Fatigue
• Late: peripheral cyanosis
III-ECG:-Right Axis Deviation-RVH-P-Pulmonale-RBBB
-Right Axis Deviation-RVH-P-Pulmonale-RBBB
V-XRAY:-Right heart ↑-Pul Congestion
II-Ascultation:
-(S) ejection murmor overpul area-Wide Split S2
IV-Echo:
Evaluation of size and type
• Associated abnormalities
• Direction of shunt
• Size of RA and RV
• Qp/Qs ratio
• TEE

^^^TX:I-Percutanous Defect Closure:-Ind : Qp/Qs >1.5+RV overload-Contra : irreverible Pul HBP-HEart& Lung Transplant: Eisenmenger-Follow-up valve suegery-Vit K Antagonist***IE :^^^CRITERIA

Major Criteria:
Minor:
I-(+) Blood Culture , Common ednocarditis1- (+)microganism from 2 BC typical of endocaridits2-(+) BC drawn >12 H apart typical of endocarditis3-Coxiella burnettri  serological involvmentII-(+) Echocardiogram or new murmor:1- oscillating intracardiac mass on heart valve2-cardiac abscess3-Vavular regugitation
-predisposing heart disoder-IV X useFever>38-Vascular phemino:1-Atrial thrombi2-infarction-Immunological phenome:1-Gnphtiis2-Rh fact-Microbiological evidance


-2 Major-1 Major+3 Minor-5Minor^^^^Tx:

^^Empirical:
^^STrepto:
^^Staphylocii:
^^Enterococci:
Ampicilin+oxacillin+gentamycin
-Pen+genta-Amoxicillin-Ceftriaxone
-Oxacillin-clndamycin-Vanco
-Amoxillin-Ampiccilin+gentacum

Ax therapy 4-6W