ischaemic heart disease. aims and objectives n ischaemic heart disease –definition,...
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Aims and ObjectivesAims and Objectives
IschaemicIschaemic heartheart diseasedisease– Definition, manifestations, epidemiology, Definition, manifestations, epidemiology,
aetiology, pathophysiology, risk factors and aetiology, pathophysiology, risk factors and preventionprevention
ChestChest painpain– Differential diagnosisDifferential diagnosis
AcuteAcute myocardialmyocardial infarctioninfarction– Assessment, treatment, complicationsAssessment, treatment, complications
CardiopulmonaryCardiopulmonary resuscitationresuscitation
Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition
An imbalance between the An imbalance between the supplysupply ofof oxygenoxygen and the and the myocardialmyocardial demanddemand resulting in myocardial ischaemia.resulting in myocardial ischaemia.
AnginaAngina pectorispectorissymptom not a diseasesymptom not a diseasechest discomfort associated with abnormal chest discomfort associated with abnormal myocardial function in the absence of myocardial function in the absence of myocardial necrosismyocardial necrosis
Ischaemic heart diseaseIschaemic heart diseaseDefinitionDefinition
SupplySupply– Atheroma, thrombosis, spasm, embolusAtheroma, thrombosis, spasm, embolus
DemandDemand– Anaemia, hypertension, high cardiac Anaemia, hypertension, high cardiac
output (thyrotoxicosis, myocardial output (thyrotoxicosis, myocardial hypertrophy)hypertrophy)
Ischaemic heart diseaseIschaemic heart diseaseManifestationsManifestations
Sudden deathSudden death Myocardial infarctionMyocardial infarction Acute coronary syndromeAcute coronary syndrome Stable angina pectorisStable angina pectoris Heart failureHeart failure ArrhythmiaArrhythmia AsymptomaticAsymptomatic
Ischaemic heart diseaseIschaemic heart diseaseAetiologyAetiology
FixedFixed– Age, Male, +ve family historyAge, Male, +ve family history
ModifiableModifiable – – strong associationstrong association– Dyslipidaemia, smoking, diabetes mellitus, Dyslipidaemia, smoking, diabetes mellitus,
obesity, hypertensionobesity, hypertension ModifiableModifiable - - weak associationweak association
– Lack of exercise, high alcohol consumptionLack of exercise, high alcohol consumption
Atherosclerosis
Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology
Response to injury hypothesisResponse to injury hypothesis ATHEROSISATHEROSIS
Accumulation of cholesterol within the vessel wall intima. Accumulation of cholesterol within the vessel wall intima. Smooth muscle cell proliferationSmooth muscle cell proliferation
SCLEROSISSCLEROSISExpansion of fibrous tissueExpansion of fibrous tissue
INFLAMMATIONINFLAMMATIONChronic inflammatory cells migrate into wall, release Chronic inflammatory cells migrate into wall, release cytokinescytokines
GROWTH FACTORS/INFLAMMATORY MEDIATORSGROWTH FACTORS/INFLAMMATORY MEDIATORS
Ischaemic heart diseaseIschaemic heart diseasePathophysiologyPathophysiology
An atherosclerotic lesion
a
Schematic illustration
Endothelium Smooth muscle cell
Macrophage foam cellThrombus formation
Media(smooth muscle cells)
Lymphocytes
Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes
AtherosclerosisAtherosclerosis
Fatal / non-fatal AMI Unstable
angina
CoronaryArtery spasm
Ischaemic heart diseaseIschaemic heart diseaseAcute coronary syndromesAcute coronary syndromes FatalFatal AMIAMI
Small, fat rich plaques. Plaque RUPTURE. Small, fat rich plaques. Plaque RUPTURE. Thrombus in lipid core and on plaques surface. Thrombus in lipid core and on plaques surface. Vessel lumen OCCLUDED. Vessel lumen OCCLUDED.
NonNon--fatalfatal AMIAMIPlaque EROSION rather than rupture. OCCLUSIVE Plaque EROSION rather than rupture. OCCLUSIVE thrombus. thrombus.
UnstableUnstable anginaanginaUsually mod-severe stenosis. Multiple vessels. Collaterals Usually mod-severe stenosis. Multiple vessels. Collaterals often formed. Thrombus formation and vasoconstriction. often formed. Thrombus formation and vasoconstriction. Myocardial infarction may ensueMyocardial infarction may ensue..
Ischaemic heart diseaseIschaemic heart diseaseRisk factors and preventionRisk factors and prevention
Family HistoryFamily History SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus HypercholesterolaemiaHypercholesterolaemia Lack of exerciseLack of exercise
PRIMARY PREVENTIONPRIMARY PREVENTION
Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia
SiteSiteJaw to navel, retrosternal, left Jaw to navel, retrosternal, left submammarysubmammary
RadiationRadiationLeft chest, left arm, jaw….mandible, Left chest, left arm, jaw….mandible, teeth, palateteeth, palate
QualityQuality//severityseveritytightness, heaviness, compressiontightness, heaviness, compression
Chest PainChest PainMyocardial ischaemiaMyocardial ischaemia
Precipitating/relieving factorsPrecipitating/relieving factors
physical exertion, cold windy weather, physical exertion, cold windy weather, emotionemotion
rest, sublingual nitratesrest, sublingual nitrates Autonomic symptomsAutonomic symptoms
sweating, pallor, peripheral sweating, pallor, peripheral vasoconstriction, nausea and vomitingvasoconstriction, nausea and vomiting
Acute Myocardial InfarctionAcute Myocardial InfarctionAssessmentAssessment
Symptoms and signs of myocardial Symptoms and signs of myocardial ischaemiaischaemia
AlsoAlso– Changes in heart rate /rhythmChanges in heart rate /rhythm– Changes in blood pressureChanges in blood pressure
Acute Myocardial InfarctionAcute Myocardial InfarctionConfirming the diagnosisConfirming the diagnosis
Typical chest painTypical chest pain
Electrocardiographic changesElectrocardiographic changes– ST elevationST elevation– new LBBB (left bundle branch block)new LBBB (left bundle branch block)
Myocardial enzyme elevationMyocardial enzyme elevation– Creatine kinase (CK-MB)Creatine kinase (CK-MB)– TroponinTroponin
Acute Myocardial InfarctionAcute Myocardial InfarctionTreatmentTreatment
Rest, sit up and reassure patientRest, sit up and reassure patient OxygenOxygen Analgesia (opiate, sublingual Analgesia (opiate, sublingual
nitrate)nitrate) AspirinAspirin Prepare for basic life supportPrepare for basic life support
Acute Myocardial InfarctionAcute Myocardial InfarctionMedical treatmentMedical treatment
Rest, oxygen, analgesia, aspirinRest, oxygen, analgesia, aspirin ThrombolysisThrombolysis Primary angioplastyPrimary angioplasty Beta-BlockersBeta-Blockers ACE inhibitorsACE inhibitors
Acute Myocardial InfarctionAcute Myocardial InfarctionComplicationsComplications
Death (Death (18% within 1 hour,18% within 1 hour, 36% within 24 hours)36% within 24 hours) Non-fatal arrhythmiaNon-fatal arrhythmia Acute left ventricular failureAcute left ventricular failure Cardiogenic shockCardiogenic shock Papillary muscle rupture and mitral Papillary muscle rupture and mitral
regurgitationregurgitation Myocardial rupture and tamponadeMyocardial rupture and tamponade Ventricular aneurysm and thrombusVentricular aneurysm and thrombus