Coronary insufficiency

พ.ต.อ.นพ.เกษม รตนสมาวงศ

13 March 2014

Content

• Definition / terminology • Cause / pathogenesis• Manifestation • Investigation• Prognosis• Treatment

คำาถามทตองตอบใหได• For underwritter

– ผเอาประกนเปน CAD หรอไม– ทราบไดอยางไร– จะตองตรวจเพมเตมอยางไร จงจะเหมาะสม– ถาเปน CAD จรง มความรนแรงเพยงใด

• For claim– ผมา claim เปน MI หรอไม– ทราบไดอยางไร / รนแรงเพยงใด

Coronary insufficiency

• Definition / terminology– Myocardial demand and supply mismatch– Myocardial ischemia– Ischemic heart disease– Coronary artery disease– Acute coronary syndrome

Anatomy or physiology

Coronary insufficiency

• Cause / pathogenesis– Atherosclerosis– Non-atherosclerosis

• Vasculitis• Embolism• Etc.

Atherosclerosis

• ปจจยเสยงของการเกดโรค–สบบหร–ความดนโลหตสง–เบาหวาน–ไขมนในเลอดสง–กรรมพนธ / ประวตครอบครว–เพศ : ชาย อาย > 45 ป หญงอาย > 55 ป

Manifestations

• กลมอาการเจบเคนอก• เหนอยงายขณะออกแรง• กลมอาการของภาวะหวใจลมเหลวทงชนด

เฉยบพลนและเรอรง• อาการเนองจากความดนโลหตตำาเฉยบพลน• อาการหมดสตหรอหวใจหยดเตน

Spectrum of disease

• Silent ischemia• Chronic stable angina• Acute coronary syndrome

– Unstable angina– Acute nonST elevation MI / NQWMI– Acute ST elevation MI / QWMI

Chest pain : Classic angina

- a dull , substernal discomfort

- radiate to left arm or neck

- associated with shortness of breath,

palpitations, sweating, nausea, vomiting

Typical angina (definite)

• Substernal chest discomfort with a characteristic quality and duration that is

• provoked by exertion or emotional stress• relieved by rest or nitroglycerine

Atypical angina ( probable ): meets 2 of the above characteristics

Noncardiac chest pain: meets < 1 of the typical angina characteristics

Investigations

• Determine myocardial ischemia• Determine myocardial scar from infarction• Determine coronary anatomy

– coronary artery stenosis ?– Degree and extent of stenosis ?

Investigations in IHD• Basic investigations

– EKG– Echocardiography– Exercise stress test

• Advanced investigation– CTA coronary artery– Dobutamine stress echo– MIBI scan– Cardiac MRI

EKG : Assessment IHD

• EKG of IHD :– inverted T wave, ST depression -> myocardial ischemia– ST elevation -> myocardial injury– abnormal Q wave -> myocardial infarction

• EKG of acute MI : – ST elevation with inverted T wave and Q wave

EKG could be normal in one-half of patients with chronic stable angina

Abnormal EKG in absent of clinical heart disease

• QS complex in AVL,V1-2 . QS or QR complex in III,AVF.

• Tall R inV1 and V2. High voltage R wave over left ventricle

• ST elevation : early repolarization• Inverted T wave : nonspecific T wave

changes

Abnormal EKG in absent of clinical heart disease

• Nonspecific ST and T wave changes are the most common EKG abnormality

• About 50% of abnormal tracings recorded in a general hospital population

• most common cause of “ iatrogenic EKG heart disease”

• must always be correlated with all available clinical and laboratory information

Information from Echocardiography

• Cardiac valves morphology & chamber enlargement , hypertrophy ?

• LV systolic and diastolic function & regional wall motion abnormality

• Valves function : stenosis & regurgitation• Pericardial effusion, vegetation & thrombus• congenital heart disease : ASD,VSD,PDA• Aortic dissection

Echocardiography in IHD

• Assess global LV function and RWMA– Myocardial ischemia -> hypokinesia– Myocardial infarction -> akinesia /

dyskinesia or aneurysm• Could be normal in chronic stable

angina• abnormal in acute / recent or old MI

Exercise stress test

• For Dx IHD – Overall sensitivity about 75% ( negative test

not excluded )• For assess IHD : high / low risk• Limitation in young, middle age female,

abnormal baseline EKG ( false positive is high )

Exercise stress test

• Specificity is less in women than men• lower prevalence and extent of CAD in

young and middle-aged women & catecholamine effect

• LVH, LBBB, WPW syndrome : need exercise or pharmacologic imaging study

Exercise stress test

• Result of EST– Positive VS Negative– Equivocal– Inadequate– assess functional capacity : low,moderate

or high workload– assess hemodynamic response

Exercise stress test

• Assess myocardial ischemia• In case of old MI

– EST could be positive or negative– Negative EST not exclude old MI

Exercise or pharmacologic stress echocardiography

• Higher specificity• More extensive evaluation of cardiac

anatomy and function• Greater convenience,efficacy and

availability• Lower cost ( compare with stress

perfusion imaging )

Stress perfusion imaging

• MIBI scan / Thallium• Higher technical success rate• Higher sensitivity• Better accuracy in evaluating possible

ischemia when multiple rest LV wall motion abnormalities are present

Calcium score

Calcium score : use for risk stratification

CTA coronary artery

CTA coronary artery : for R/O CAD

Cardiac MRI• Useful in IHD and other cardiovascular disease• In IHD : use for assess myocardial function, myocardial

ischemia , viable myocardium and myocardial infarction

Coronary angiography

• Invasive test• Gold standard for Dx IHD• single or double or tripple vessel disease• Involve left main ? • % of stenosis• Assess LV function by LV ventriculogram

Acute MI

• Criteria for diagnosis– Chest pain : Angina– EKG changes : evidence of myocardial ischemia

and injury– Cardiac biomarkers : rising of troponins, CK-MB

Timing of cardiac biomarkers measurementis important for diagnosis !!!

Biomarkers in Acute Coronary Syndrome Detection, sensitivity and specificity for AMI

2 - 3 d7 - 14 d7 - 10 d1 - 2 d8 -12 h

Duration of Detection

++++++++++++++++

Sensitivity

4 – 6 h3 – 4 h3 – 4 h2 – 3 h

1.5 – 2 h

First Detection

++CK Total++++Troponin T++++Troponin I+++CK-MB+Myoglobin

SpecificityMarkers

Successful reperfusion in AMI patients accelerates the cardiac marker release.

*TIMI: Thrombolysis in Myocardial InfarctionFrench JK, White HD. Clinical implications of the new definition of myocardial infarction. Heart (2004) 90: 99 –106

Prognosis

• เปนโรคเรอรง : ไมหายขาด• สาเหตการเสยชวต : Heart failure / cardiac

arrhythmias• ความรนแรงหรอการพยากรณโรคขนกบ

– LV function / previous MI ?– Extent of disease / area of ischemia– High risk criteria from noninvasive test

การรกษา IHD

• การรกษาดวยยา • การรกษาดวยวธ Balloon • การรกษาดวยการผาตด Bypass