principles of diagnsosis of ischemic heart disease
DESCRIPTION
Principles of diagnsosis of ischemic heart disease. Mohammad Hashemi Interventional cardiologist Department of cardiology. Ischemic chest pain due to coronary artery disease (CAD). - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/1.jpg)
Principles of diagnsosis of ischemic heart diseaseMohammad HashemiInterventional cardiologistDepartment of cardiology
![Page 2: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/2.jpg)
Ischemic chest pain due to coronary artery disease (CAD)
stable angina pectoris, unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction.
![Page 3: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/3.jpg)
The differential diagnosis of patients presenting with chest pain is extensive
![Page 4: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/4.jpg)
![Page 5: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/5.jpg)
Ischemic chest pain due to coronary artery disease Patients classically complain of chest heaviness,
pressure, tightness or burning, but may vigorously deny "pain.
Other descriptions such as provocation with physical or emotional stress or cold, relief with rest, and radiation to the neck, jaw, and shoulder are common.
Ischemic pain usually lasts more than 2 but less than 20 minutes, unless a myocardial infarction is occurring.
Associated symptoms may include dyspnea, nausea and vomiting, diaphoresis, presyncope, or palpitations.
![Page 6: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/6.jpg)
The correct diagnosis is based on
detailed history (pain description; associated symptoms; and in some cases disease risk factors) that is
supported by specific physical findings,
an electrocardiogram, and/or chest x-ray.
![Page 7: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/7.jpg)
EVALUATION
The office evaluation of new onset chest pain in stable individuals should begin with the consideration of imminently life-threatening causes (including acute coronary syndrome, pulmonary embolus, aortic dissection, pneumothorax, and esophageal rupture).
![Page 8: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/8.jpg)
This is usually accomplished using clinical judgement, along with ECG testing, and less frequently exercise testing, other noninvasive testing, or invasive angiography.
![Page 9: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/9.jpg)
The clinical evaluation is also useful to estimate the pretest probability of organic causes of chest pain prior to undergoing diagnostic tests (eg, stress ECG testing to detect CHD or d-dimer, CTa-angiography or lung perfusion scanning to detect pulmonary embolism).
Pretest probability is an important component of the interpretation of these test results.
![Page 10: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/10.jpg)
The history typical chest pain is less useful in patients suspected of having an acute coronary syndrome (ACS)
Conversely, in patients with stable, intermittent chest pain, a description of typical angina (ie, substernal discomfort, precipitated by exertion, improved with rest or nitroglycerin in less than ten minutes with many patients reporting radiation to shoulders, jaw, or inner arm) was a moderately strong predictor of obstructive epicardial CHD .
![Page 11: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/11.jpg)
Description of chest pain
Descriptions of chest discomfort due to myocardial ischemia may differ depending on: patients' culture, gender, age and presence of comorbid conditions
such as diabetes.
![Page 12: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/12.jpg)
Quality of the pain
Region or location of painRadiationProvocationSeverity Palliation
![Page 13: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/13.jpg)
Associated symptoms Belching, Belching, Vomiting Diaphoresis Dyspnea Cough Syncope Palpitations Psychiatric symptoms Constitutional symptoms —particularly in
elderly may describe profound fatigue.
![Page 14: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/14.jpg)
Risk factors
The clinical impression raised by the patient's description of pain must be interpreted together with other aspects of the history, including risk factors for various etiologies of chest pain
![Page 15: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/15.jpg)
Risk factors
A history or lack of classical coronary risk factors does not usefully discriminate ischemic causes of chest pain in the acute setting
![Page 16: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/16.jpg)
Physical examination A brief, "core" examination may suffice to diagnose
life-threatening and common etiologies of chest pain. The general appearance A full set of vital signs Palpation of the chest wall may evoke pain A complete cardiac examination including
auscultation and palpation Determine if the breath sounds are symmetric A careful examination of the abdomen is important Focal neurologic signs
![Page 17: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/17.jpg)
Electrocardiogram
Normal electrocardiogram A normal ECG markedly reduces
the probability that chest pain is due to acute myocardial infarction, but it does not exclude a serious cardiac etiology (particularly unstable angina).
![Page 18: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/18.jpg)
Abnormal electrocardiogram
The ECG is valuable both for risk stratification and diagnosis of acute myocardial infarction.
![Page 19: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/19.jpg)
Stress testing for the diagnosis of coronary heart disease
The major questions to be addressed before selecting one or more of the available diagnostic tests are:
What is the patient's pretest risk of CHD? How accurate are the alternative tests? What are the costs and effects on health outcomes of
each test? Do special considerations make one test more suitable in
a specific patient?
![Page 20: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/20.jpg)
PRETEST PROBABILITY
An initial estimate of the likelihood of CHD is based upon the clinical history.
The pretest probability determines the need for noninvasive diagnostic tests or even coronary arteriography
![Page 21: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/21.jpg)
Estimating pretest probability Definite or classic angina — Substernal
chest discomfort characterized by all of the following characteristics: a typical quality and duration, provocation by exertion or emotional stress, and relief by rest or nitroglycerin
Probable or atypical angina — Chest pain with two of the three above characteristics
Nonanginal or nonischemic chest pain — Chest pain with one or none of the above characteristic
![Page 22: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/22.jpg)
![Page 23: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/23.jpg)
Estimating pretest probability
It should be noted that asymptomatic patients have a low pretest probability of significant CHD, and generally are not screened by use of stress testing.
Symptomatic patients with moderate risk of CHD may be considered for stress testing .
![Page 24: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/24.jpg)
NON-INVASIVE TESTS Exercise ECG testing is the most
commonly used noninvasive test because it is simple and inexpensive.
Echocardiography using either exercise or pharmacologic (dobutamine or dipyridamole) stress.
Radionuclide myocardial perfusion imaging using either exercise or pharmacologic stress.
![Page 25: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/25.jpg)
Women
Diagnosing coronary artery disease is more difficult in women than men for the following reasons: Women are less likely to present with (or report
during treadmill testing) typical angina. False positives test results during exercise ECG
testing are more common.
![Page 26: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/26.jpg)
Limitations of exercise stress
The exercise ECG cannot be interpreted in the presence of resting ST segment changes, left ventricular hypertrophy, left bundle branch block, a ventricular paced rhythm, or the Wolff Parkinson White syndrome.
The patient must also be able to exercise adequately,
![Page 27: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/27.jpg)
Exercise ECG testing is the most commonly used noninvasive test because it is simple and inexpensive.
![Page 28: Principles of diagnsosis of ischemic heart disease](https://reader036.vdocuments.net/reader036/viewer/2022062410/568165c0550346895dd8c2b5/html5/thumbnails/28.jpg)
INVASIVE TESTS
Coronary angiography is the definitive diagnostic test for the presence of obstructive coronary artery disease.
However, it is seldoam used as the initial test because of its invasive nature and because the presence of a lesion does not prove that the patient's symptoms are due to ischemia.