Ischemic heart disease/Coronary heart disease

Written by Dr.Md.Redwanul Huq (Masum)
Sunday, 15 January 2012 15:58

Ischemic heart disease(IHD):

 

Definition:

Ischemic heart disease (IHD) is characterized by ischemia (reduced blood supply) of the cardiac muscles, which is usually caused by coronary artery diseases. It is also known as Coronary heart disease.

Ischemic heart diseases include the following:

1. Stable angina (Stable angina pectoris)

2. Unstable angina

3. Myocardial infarction(MI) –

a) Non-ST-elevation MI

b) ST-Segment elevation MI.

Risk factors of coronary heart disease:

Major risk factors of coronary heart disease:

1. More age

2. Male

3. Family history of IHD

4. Genetic disorder

5. Diabetes Mellitus

6. Dyslipidemia

7.Cigarette smoking

8. Hypertension.

Minor risk factors of coronary heart disease:

  1. Sedentary physical activity
  2. Stress
  3. Obesity
  4. Excess intake of Carbohydrate & fat
  5. Postmenopausal women( due to estrogen deficiency)
  6. Alcohol intake
  7. Infection by Chlamydia pneumoniae
  8. Lipoprotein disorder.

1. Stable angina pectoris:

Definition:

It is a clinical syndrome which is caused by transient myocardial ischaemia.

History:

i. Middle age(usually male) or old age(both male & female)

ii. Family history of IHD

iii. H/O (History of) Diabetes Mellitus, Dyslipidemia, Cigarette smoking or Hypertension.

Symptoms:

  • Chest pain- usually on exertion (e.g., exercise, sexual activity, hurrying etc) or emotion (e.g., anger, stress, frustration, fright etc) or after a heavy meal or exposure to cold or a combination (Chest pain may also develop at rest), which is –
  1.  Retrosternal (central)
  2. Constricting, squeezing, smothering, choking, heavy or burning in nature and rarely as frank pain
  3. Radiates to the arms, in between scapulae, face, throat, back, root of the neck, teeth, jaw, epigastrium or other areas
  4. Is relieved by rest or medicine
  5. Usually lasts for a short time (2 – 5 minutes)
  6. Increased by heavy meal, physical exertion, exposure to cold, emotion etc
  7. Feelings like gas or indigestion
  •  Chest discomfort usually on exertion (e.g., exercise, sexual activity, hurrying etc) or emotion (e.g., anger, stress, frustration, fright etc)
  • Shortness of breath usually on exertion (e.g., exercise, sexual activity, hurrying etc) or emotion (e.g., anger, stress, frustration, fright etc).

Signs:

Following signs may be present in patients with Stable Angina-

  •  Hypertension
  • Abdominal aortic aneurysm
  • Cardiac enlargement
  • Gallop rhythm
  • Diminished arterial pulses in lower extremities
  • Carotid arterial bruits
  • Fundoscopy may reveal an increased light reflex and arteriovenous nicking in a hypertensive patient
  • Signs of Dyslipidemia-·a) Xanthomas b) Xanthelasmas.
  • Nicotine stains on the fingertips in a cigarette smoker patient
  • Anemia
  • Thyrotoxicosis.

Investigations:

  •  Resting ECG: may be normal, may show Q waves as evidence of previous myocardial infarction, occasionally, T-wave may be flat or inverted in some leads. The most significant ECG findings of myocardial ischaemia are reversible ST segment depression or elevation, with or without T-wave inversion, at the time of chest pain or discomfort.
  • Exercise ECG: Exercise tolerance test (ETT)- ECG shows down-sloping ST segment depression of 1 mm or more.
  • Isotope perfusion scan: It shows exertional perfusion defects.
  • Coronary arteriogram (angiogram): It provides anatomical information about the extent and nature of coronary artery disease.
  • Urine R/M/E: To see the evidence of renal disease and diabetes mellitus (including microalbuminuria).
  • Blood glucose: To rule out diabetes.
  • Fasting lipid profile: To rule out dyslipidemia.
  • Serum Creatinine: To exclude renal disease.
  • Hematocrit.
  • Thyroid function test (if needed).

Treatment of coronary heart disease/Treatment for angina pectoris:

* Explanation of the disease to the patient

* Reassurance to the patient about the ability to provide a treatment plan for the disease

* Anti-anginal drug treatment of coronary heart disease

1. Sublingual nitroglycerin-

Glyceryl Trinitrate spray /aerosol

-2 puff sub-lingually during chest pain

or,  before any physical exertion ———–sos.

2. Nitrates-

Tab. Glyceryl Trinitrate (2.6 mg)

1 tab-bid  —————————-1 or 2 M or contd.

Or,

Tab.Isosorbide Mononitrate (20 mg)

1+1+0 (2 days off in a week) —– 1 or 2 M or contd.

3. Beta-blockers

Tab. Atenolol (50/100 mg )

1 tab-once daily( +M) ———————–contd.

Or,

Tab. Metoprolol Tartarate (50 /100 mg)

1 tab-once daily( +M) ———————–contd.

4. Calcium channel blockers-

Tab. Amlodipine (5 /10 mg)

1 tab-once daily (+M) ———————–contd.

Or,

Tab. Nifedipine (10 / 20 mg)

1 tab- tid (±M) ——————————–contd.

Or,

Tab. Verapamil (40 / 80 mg)

1 tab- tid (AM) ——————————–contd.

Or,

Tab. Diltiazem (30/60/90/120 mg)

1 tab- tid (±M) ——————————–contd.

5. Antiplatelet Drugs-

Tab. Aspirin (75 mg)

1tab-once daily (AM, usually after launch) —————– contd.

Or,

Tab.Clopidogrel (75 mg)

1tab-once daily ( AM, usually after launch) —————– contd.

Or,

Tab.Aspirin & Tab.Clopidogrel (75/75 mg) combination

1tab-once daily ( AM, usually after launch) —————– contd.

* Treatment of significant risk factors

a) Treatment of Hyperlipidemia:

I. If Serum Cholesterol  level is high-

Tab. Atorvastatin (10 /20/40 mg)

Or,

Tab. Rosuvastatin Calcium(5/10mg)

1 tab-once daily( +M) ———————–contd.

II. If serum Triglyceride level is high-

Cap. Fenofibrate (200 mg)

1 cap-once daily (AM)————————2 /3 M or contd.

Or,

Cap. Gemfibrozil(300mg)

1 Cap- once daily/bid ( ½ HBM) ———————2 /3 M or contd.

III. Tab.Trimetazidine (35mg)

1tab-once daily (AM) ————————2 /3 M or contd.

b) Treatment of Diabetes Mellitus.

c) Treatment of Hypertension:

* Identification and treatment of aggravating factors

The following factors can aggravate angina and therefore should be managed as a part of treatment for angina pectoris, if present-

  •  Hypertension
  • Aortic valve disease
  • Hyperthyroidism
  • Hypertrophic cardiomyopathy
  • Obesity
  • Pulmonary disease
  • Anemia.

* Recommendations for adaptation of physical activity

Patients with IHD should be recommended to adapt their activities in employment

or residence to reduce stress & thereby angina.

* Invasive treatment for revascularization

  • Percutaneous transluminal coronary angioplasty, PTCA-

It is the balloon dilatation of coronary stenosis which is usually accompanied by coronary stenting. Indications are:

  1.  Single or two-vessel disease
  2. Stenoses in the native coronary arteries
  3. Stenoses in bypass grafts
  4. Palliative treatment for patients with recurrent angina after CABG
  5. Stenosis of left main coronary artery and patients with three-vessel disease i.e. involving left anterior descending, circumflex and right coronary arteries (in patients who are non-diabetic and have good LV function).
  • Coronary artery bypass grafting, CABG

One or both of the internal mammary arteries, radial arteries or reversed segments of the patient’s own saphenous vein can be used to bypass coronary artery stenoses. Indications are:

  1.  Stenosis of left main coronary artery and patients with three-vessel disease (specially in patients with diabetes and/or impaired LV function, LVEF <50%)
  2. Two-vessel disease involving the proximal left anterior descending coronary artery
  3. Patients with recurrent stenosis following PTCA and high-risk criteria on noninvasive testing
  4. Patients who have undergone previous CABG.

LIFESTYLE MODIFICATION:

  • Try to increase physical activity
  • Don’t smoke
  • Exercise regularly ( at least 30 – 45 mts of moderate intensity physical activity like walking, jogging, cycling or swimming on most days of the week)
  • Avoid extra salt
  • Stop taking alcohol
  • Control your body weight.

DIETARY MODIFICATION:

  •  Decrease intake of saturated fat, polyunsaturated fat and transfatty acids and therefore decrease intake of butter, fatty meats, margarine, dairy products made from 2% or whole milk.
  • Use oils containing monounsaturated fatty acids and n-3 fatty acids (eg, canola and olive oil).
  • Eat monounsaturated-rich nuts in moderation.
  • Eat at least five to seven servings of vegetables and fruits daily.
  • Eat soy products and legumes daily.
  • Eat garlic regularly.
  • Increase intake of soluble fiber ( Present in Apples, Barley, Citrus fruits, Strawberries, Carrots, Guar, Legumes).