The document discusses ischemic heart disease (IHD), including its causes, symptoms, types (such as stable angina, unstable angina, and myocardial infarction), risk factors, diagnosis, and management. IHD is caused by reduced blood flow to the heart muscle, usually due to coronary artery disease. It presents with chest pain and other symptoms and is diagnosed through electrocardiograms, exercise tolerance tests, echocardiograms, isotope scans, and coronary angiography. Investigation aims to determine the severity and location of arterial blockages for guiding revascularization procedures.

1. Ischemic Heart disease
Ahmed Dabour
Hussain Salha
Osama Nofal

2. Ischemic Heart
disease
Causes and symptoms

3. ischemic heart disease
ischemic heart disease (IHD):
is a disease characterized by reduction blood supply of the heart
muscle, usually due to coronary artery disease
 1-Angina  2-Myocardial infarction
 Stable  STEMI
Angina
 Unstable Angina  NSTEMI
 Variant Angina
 decubitus angina
 nocturnal angina

4. Epidemiology
• most common cause of cardiovascular morbidity and mortality
• atherosclerosis and thrombosis are the most important
pathogenetic mechanisms.
• peak incidence of symptomatic IHD is age 50-60 (men)
and 60-70 (women)
M>F

5. Etiology
 1-Decreased coronary blood flow due to mechanical obstruction
such as:
 Atheroma
 Spasm of coronary artery
 Thrombosis
 Embolism
 Coronary artreritis
 2- Increased myocardial oxygen requirement :
 Increased cardiac output :thyrotoxicosis
 Myocardial hypertrophy: aortic stenosis , hypertension
 3-Decreased flow of oxygenated blood :
 anemia

7. Angina pectoris
 Isa clinical syndrome characterized by paroxysmal chest pain
due to transient myocardial ischemia . It may occur whenever
there is imbalance between myocardial oxygen supply and
demand the most common cause is atherosclerosis .however
angina may also develop in aortic stenosis and hypertrophic
cardiomyopathy even there is no coronary atheroma

8. Angina symptoms include:
 Chest pain or discomfort Chest pain or discomfort is
 Pain in your arms, neck, usually felt as:
jaw, shoulder or back pressure,
accompanying chest pain heaviness,
 Nausea
tightening,
 Fatigue
squeezing,
 Shortness of breath
 Anxiety
 Sweating
 Dizziness

9. Stable Angina
 Atherosclerotic coronary artery disease
 occurs when the heart has to work harder than normal, during
exercise
 typical: retrosternal chest pain, tightness or discomfort
 radiating to left(± right) shoulder/arm/ neck/jaw,
 brief duration, lasting <10-15 min
 associated with diaphoresis, nausea, anxiety
 typically relieved by rest and nitrates

10.  precipitatedby the " E's"
 Emotional stress
 Exertion
 Exposure to very hot or cold temperatures
 Eating ( Heavy meals)
 And Smoking

11. Variant Angina
A spasm in a coronary artery
Usually happens when you're resting, unrelated to exercise,
relieved by nitrates
typically occurs between midnight and 8 AM,
The coronary arteries can spasm as a result of:
Exposure to cold
Emotional stress
Medicines that tighten or narrow blood vessels
Smoking
Cocaine use

12. SYNDROME X
 Coronary microvascular disease that affects the heart’s
smallest coronary arteries.
 Typical symptoms of angina but normal angiogram
 May show definite signs of ischemia with exercise testing

13. Unstable Angina
 Due to spasm and partial obstruction of coronaries.
 Occurs even at rest
 Is unexpected (new onset)
 Is usually more severe and lasts longer than stable angina,
may be as long as 30 minutes
 May not disappear with rest or use of angina medication
 May lead to complete occlusion of vessel causing MI

14. Myocardial Infarction
 Myocardial infarction, commonly known as a heart attack,
is the irreversible necrosis of heart muscle secondary to
prolonged ischemia (total obstruction)
 Typical symptoms of myocardial infarction include
 sudden chest pain,
 shortness of breath,
 nausea, vomiting,
 palpitations, sweating
 weakness, light-headedness
 Collapse/syncope

15.  Severe pain
 described as a sensation of tightness, pressure,crushing or
squeezing.
 radiating to left(± right) shoulder/arm/ neck/jaw
 Chest pain usually lasts for more than 15 minutes
 Not relieves by rest

16. Ischemic Heart
disease
Physical examination

17. Physical examination & signs in angina:
•For most patients with stable angina, physical examination
findings are normal. Diagnosing secondary causes of angina,
such as aortic stenosis, is important.
•Vital signs especially blood pressure
•A positive Levine sign (characterized by the patient's fist
clenched over the sternum when describing the discomfort) is
suggestive of angina pectoris.

19. •Look for physical signs of abnormal lipid metabolism (eg,
xanthelasma, xanthoma) or of diffuse atherosclerosis (eg,
absence or diminished peripheral pulses, increased light
reflexes or arteriovenous nicking upon ophthalmic
examination, carotid bruit).
•Examination of patients during the angina attack may be more
helpful. Useful physical findings include third and/or fourth
heart sounds due to LV systolic and/or diastolic dysfunction
and mitral regurgitation secondary to papillary muscle
dysfunction.
•Pain produced by chest wall pressure is usually of chest wall
origin.

20. Physical examination & signs in unstable angina
and myocardial infarction
Abnormal physical findings are often absent; when present, they are often non-
specific.
An unremarkable physical examination is not uncommon. Perform a quick
assessment of patients' vital signs, and perform a cardiac examination.
Specific diagnoses that must be explicitly considered are the following:
•Aortic dissection
•Leaking or ruptured thoracic aneurysm
•Pericarditis with tamponade
•Pulmonary embolism
•Pneumothorax

21. Unstable angina differs from stable angina in that the discomfort is
usually more intense and easily provoked, and ST-segment depression
or elevation on ECG may occur.
Otherwise, the manifestations of unstable angina are similar to those
of other conditions of myocardial ischemia, such as chronic stable
angina and myocardial infarction.

22. Increased autonomic activity may manifest as diaphoresis or tachycardia, and
bradycardia may result from vagal stimulation from inferior wall myocardial
ischemia.
A large area of myocardial jeopardy may manifest as signs of transient myocardial
dysfunction and typically signifies a higher-risk situation. Signs include the
following:
•Systolic blood pressure less than 100 mm Hg or overt hypotension
•Elevated jugular venous pressure
•Dyskinetic apex
•Reverse splitting of the second heart sound
•Presence of a third or fourth heart sound
•New or worsening apical systolic murmur due to papillary muscle dysfunction
•Rales or crackles

23. Vital signs and appearance are two of the most important aspects of the physical
exam.
Vital Signs
In the evaluation of a patient presenting with ACS hypotension (systolic blood
pressure <100 mm Hg), tachycardia (pulse >100) and bradycardia (pulse <60
bpm) indicate that a patient is at higher risk.
As with the assessment of all patients, other abnormal vital signs such as hypoxia,
tachypnea (RR >19), hypothermia (T <95 F) or fever (T >100.3 F) should raise
concern, although they are not specifically suggestive of ACS.
If aortic dissection is considered in the differential diagnosis, blood pressure
should be checked in both arms (>20 mm Hg differential is suggestive of aortic
dissection).
Appearance of the Patient
A patient who appears anxious, diaphoretic, with pale skin and who is in obvious
respiratory distress should demand immediate attention.

24. Eyes
The eye exam is typically not the focus of a physical exam for ACS, however,
details such as pale conjunctiva (suggestive of anemia), exopthalmos (suggestive
of hyperthyroidism), or cotton-wool spots (suggestive of hypertension), or
retinopathy (suggestive of diabetes) on fundoscopic exam should be noted as they
may allow for the identification of potential precipitants of or risk factors for
myocardial ischemia.
Ear Nose and Throat
The ears and nose are typically not the focus of a physical exam for ACS.
However, the examination of the buccal mucosa can help to determine a patient's
volume status, as can the examination of the right internal jugular vein pulsations
(JVP).
A JVP which is elevated greater than 4 cm above the sternal angle (9 cm above
the right atrium) is considered elevated and reflects elevated right atrial pressure.

25. Heart
The cardiac exam should evaluate for signs of cardiac failure, such as a 3rd heart
sound ("gallop," from early diastolic filling from left ventricular systolic failure), a
4th heart sound ("gallop," from late diastolic filling from a stiff left ventricle, as
from diastolic heart failure) or a new / increased systolic murmur of mitral
regurgitation (as from papillary muscle rupture).
The presence of a pericardial rub would suggest pericarditis instead of ACS.
Lungs
Bibasilar rales are suggestive of congestive heart failure and pulmonary edema.
However, the absence of adventitious lung sounds does not preclude diastolic heart
failure.
Abdomen
The abdominal exam is typically not the focus of a physical exam for ACS.
However, a finding of a expansile, pulsatile mass in the upper abdomen suggests an
aortic aneurysm and requires further urgent evaluation.

26. Extremities
Assess the lower extremities for edema, suggestive of heart failure. It is also
important to palpate the radial, femoral and pedal pulses.
Unequal radial pulses are suggestive of aortic dissection. Weak pedal pulses are
suggestive of peripheral vascular disease. Femoral pulses are important to
document in the event that cardiac catheterization is necessary.
Neurologic
The neurological examination is typically not the focus of a physical exam for
ACS. However, mental status at the time of the initial assessment should be
documented for future reference, should the patient's mental status deteriorate
during the period of observation.
Also, headache in the context of chest pain and severe hypertension (i.e., SBP >
210 mm/Hg or a DBP > 120 mm/Hg) would support a diagnosis of hypertensive
emergency as a cause for ACS.

27. Ischemic Heart
disease
Investigation

28. 1-ECG
 Differential diagnosis of ST segment depression
 Myocardial Ischemia
 LVH
 Severe hypertension
 Cardiomyopathy
 Anemia
 Hypokalemia
 Digitalis effect

29. Differential diagnosis of ST segment elevation
 Myocardial infarction
 Prinzmetal’s angina
 Ventricular aneurysm (post MI )
 Acute pericarditis
 Myocarditis
 Hypothermia

30. 2-Exercise Tolerance Test (ETT)
 This is the most useful noninvasive procedure for
evaluation the patient with angina. Ischemia that is
not present at rest is detected by precipitation of
typical chest pain or ST segment elevation during
the exercise using treadmill
 When history is suggestive of angina pectoris but
ECG is normal , then the exercise test should be
done.

31.  The test involves recording the 12-lead ECG
before , during and after exercise.
 The test consists of a standardized incremental
increase in the external workload while the
patient’s ECG, symptoms and the blood pressure
are continuously monitored. A variety of exercise
protocols are utilized, the most common being the
Bruce protocol which increases the treadmill speed
and elevation every 3 mins until limited by
symptoms.

32.  This test discovers any limitation in exercise
performance and establishes the relationship between
chest pain and the typical ECG sings of myocardial
ischemia.
 Positive test is one which ST segment is depressed by
1mm(one small square )
 More severe disease presents with ST depression more
2 mm at low workload or at heart rate less than 70% of
age predicted value, or hypotension develops during
exercise.

33. ETT Report:
 Degree of ST depression
 Development of arrhythmia or conduction defect
during and post exercise.
 Duration of exercise.
 Achievement of age predicted target heart rate ( 220
minus age )
 Development of chest pain during exercise.
 Hemodynamic response

34. Indications:
 To confirm the diagnosis of angina
 To determine the severity of limitation of activity
due to angina
 To asses prognosis in patient with known coronary
disease.
 To evaluate response to therapy.

35. Contraindications:
 Acute myocardial infarction ( less 2 days )
 High risk unstable angina
 Decompensated HF
 Cardiac arrythmias with symptoms
 Heart block
 Acute myocarditis and pericarditis
 Severe aortic stenosis
 Severe HOCM
 Uncontrolled HTN

36. Interpretation:
 Overall sensitivity of ETT is about 60-75% and
specificity 80%. The test may be falsely + or – in
15% of cases therefore negative test does not rule
out IHD and positive test without symptoms does
not always confirm IHD. If ERR is inconclusive
then IHD should be confirmed by thallium scan.
ECHO and angiography.

37. Echocardiograph
 Itreveals segmental wall motion abnormalities
which indicate ischemia or prior infarction. It can
be performed at rest while sensitivity increase if
performed after exercise or stress given by
dobutamine (called dobutamine stress echo)

38. Isotope scanning
 Thallium scan and technetium scan shows areas of reduced
uptake of radioactive isotope (thallium and technetium) by
the myocardium. This test is performed at rest and during
stress (produced by exercise or dipyridamol or dobutamine)
 A perfusion defect present during stress but not all rest
indicates reversible myocardial ischemia, whereas a
persistent perfusion defect on scan during both phases (rest
and stress) usually indicates previous myocardial infarction.
 Thallium scanning is positive in 75-90% of patients with
significant coronary disease. False positive test may occur in
women due to breast tissue.

39. Indication:
 When ETT is not diagnostic (equivocal or contrary to the clinical
impression such as positive test in asymptomatic patient).
 When patient is unable to perform exercise e.g. patient of unstable
angina, aortic stenosis or handicapped patients. In these patients
stress is produced by alternatives methods such as drugs e.g.
dipyridamol dobutamine or adenosine
 To distinguish ischemia from myocardial infarction.
 To localize regions of ischemia.
 To identify whether the myocardium is viable or not, because
revascularization via surgery or angioplasty may be beneficial only
for viable myocardium.

42. Coronary angiograph
 Coronary angiography visualizes the location and
severity of coronary after stenosis. Narrowing
greater than 50% of luminal diameter is considered
clinically significant, although most lesion
producing ischemia are associated with narrowing
more than 70%.

43. Indication:
 Coronary angiograph is indicated in patient whom coronary
revascularization (angioplasty or by-pass) is being considered
because of uncontrolled stable angina who have failed to
improve on adequate medical regimen
 To diagnose chest pain of uncertain cause when noninvasive
tests have failed to detect the cause. Diagnostic angiography is
now rarely performed because diagnosis is usually made on
history and non-invasive tests.
 Unstable angina
 Post myocardial infarction angina
 Severe left ventricle dysfunction after MI
 Non Q-wave MI
 Strongly positive ETT