A 50 year old male teacher

notices the sudden onset of

CASE 2 chest tightness when he walks
across the parking lot to and
from the school. The pain, which
is localized over the sternum,
goes away when he sits down.
He does not experience any pain
or discomfort at other times. He
has mild hypertension, for which
he is on dietary therapy. His
cholesterol level is elevated. He
does not smoke.
CHIEF COMPLAINT

CHEST
TIGHTNESS
Clinical Scenario: History

Male, 50 yrs. Old

Chest tightness when walking for a
Short distance
Pain over the Sternum
Pain is relieved by Sitting down
Hypertensive
Hypercholesterolemia
On Diet Therapy
 Differential Diagnosis

Pericarditis
Acute Myocardial Infarction
Stable Angina Pectoris
ANGINA PECTORIS
 Angina pectoris

most common clinical manifestation of CAD

results from an imbalance between myocardial O2

supply and demand, most commonly resulting from
atherosclerotic coronary artery obstruction.

Other major conditions that upset this balance and

result in angina include
aortic valve disease,
hypertrophic cardiomyopathy,
coronary artery spasm.
 STABLE ANGINA
Usually develops gradually with exertion,
emotional excitement, or after heavy
meals.
Rest or treatment with nitroglycerin leads
to relief.
In contrast, pain that is fleeting is rarely
ischemic in origin.
Pain that last for several hours is unlikely
to represent angina.
 STABLE ANGINA
Most myocardial perfusion occurs during
diastole, when there is minimal pressure
opposing coronary artery flow.
Tachycardia decreases the percentage of
time in which the heart is in diastole. It
decreases myocardial perfusion.
 UNSTABLE ANGINA
Similar in quality to angina pectoris.
More prolonged ang severe.
Occur with the patient at rest, or
awakened from sleep.
Sublingual nitroglycerin may lead to
transient or no relief.
Accompanying Sx: Diaphoresis, dyspnea,
nausea and light-headedness.
 UNSTABLE ANGINA
Auscultation: During ischemic episodes
there will be presence of third or fourth
heart sounds.
This reflects myocardial systolic or
diastolic dysfunction.
Presence of transient murmur of mitral
regurgitation suggests ischemic papillary
muscular dysfunction.
 PRINZMETALS ANGINA
CAUSES: The spasm often occurs in
coronary arteries that have not become
hardened due to plaque buildup
(atherosclerosis). However, it also can
occur in arteries with plaque buildup.
The coronary artery may appear normal
during angiography, but it does not
function normally.
 PRINZMETALS ANGINA
Coronary artery spasm occurs most
commonly in people who smoke or who
have high cholesterol or high blood
pressure.
It may be triggered by:Alcohol
withdrawal,emotional stress ,exposure to
cold,medications, and stimulant drugs
such as amphetamines and cocaine.
 PRINZMETALS ANGINA
Symptoms: Spasm may be "silent" --
without symptoms -- or it may result in
chest pain or angina.
If the spasm lasts long enough, it may
even cause a heart attack.
The main symptom is a type of chest pain
called angina, felt under the chest bone
and is described as:
 PRINZMETALS ANGINA
Constricting,crushing,pressure,squeezing,
tightness.
It is usually severe. The pain may spread
to the neck, jaw, shoulder, or arm.
The pain often occurs at rest and may
occur at the same time each day,usually
between midnight and 8:00 AM
Lasts from 5 to 30 minutes
 PRINZMETALS ANGINA
The person may lose consciousness.
Chest pain and shortness of breath are
often not present during walking and
exercise.
 Angina Pectoris
P( provoking) eating too much
exercise
emotion
cold
P ( Palliating/ relieving) Rest and Nitroglycerin (
sublingual)
Q ( quality) steady; precordial pressure (hollow-
block)
- dull, aching, squeezing
R ( region) precordial
R ( radiation) - radiate to Left axilla, left under
surface of arms and forearms
little finger then
it goes up left shoulder and
jaw.
S (severity) mild-severe
Etiology of the Signs &
Symptoms
Chest Tightness (relieved by rest)

Ischemia manifests most frequently as chest

discomfort.
Myocardial ischemia occurs when the oxygen
supply to the heart is not sufficient to meet
metabolic needs. This mismatch can result from a
decrease in oxygen supply, a rise in demand, or
both
The most common underlying cause of myocardial
ischemia is obstruction of coronary arteries by
atherosclerosis
Hypertension:
Vascular radius and compliance of
resistance arteries are important
determinants of arterial pressure
With atherosclerosis, results to narrowing
of the blood vessel lumen; damage of the
arteries
Consequently small decreases in lumen
size significantly increase resistance
causing increased arterial pressure
(HPN)
Elevated Cholesterol Level

Major risk factor in the development of

atherosclerosis
The incidence of CHD is correlated with
elevated levels of LDL cholesterol and
triacylglycerols and with low levels of HDL
cholesterol.
Cholesterol levels may be elevated as a result
of an individual's lifestyle (for example, by lack
of exercise and consumption of a diet
containing excess saturated fatty acids)
Clinico- Pathologic
Correlation
Etiology
Clinical
findings
 Heart sounds

Normal heart sound Pericardial Friction rub

 MORPHOLOGY

Myocardial Ischemia
(ANGINA PECTORIS)
 Myocardial Ischemia

(also known as angina) is a heart condition

caused by a temporary lack of oxygen-rich
blood to the heart. There are three types, each
of which is signified by pain. The stable type
occurs when the heart is working harder than
usual and generally goes away with rest;
unstable myocardial ischemia is dangerous and
requires emergency treatment; variant (also
called Prinzmetal's angina) occurs at rest and
can be relieved by medicine.
 Myocardial Ischemia

There is an imbalance between the supply and

demand of the heart for oxygenated blood.
In more than 90% of cases, the cause of
myocardial ischemia is reduction in coronary
blood flow due to atherosclerotic coronary
arterial obstruction. In most cases, there is a
long period (decades) of silent, slowly
progressive, coronary atherosclerosis before
these disorders become manifest.
 Atheroma of coronary
artery

A fixed obstructive lesion

of 75% or greater (i.e.,
only 25% or less lumen
remaining) generally
causes symptomatic
ischemia induced by
exercise.
Stable angina results from increases in myocardial
oxygen demand that outstrip the ability of markedly
stenosed coronary arteries to increase oxygen delivery
but is not usually associated with plaque disruption.
A 90% stenosis can lead to inadequate coronary blood flow
even at rest. Slowly developing occlusions may stimulate
collateral vessels over time, which protect against distal
myocardial ischemia and infarction even with an eventual
high-grade stenosis.
Risk
factors
of

Angina
Pectoris
Smoking tobacco

Smoking and long-term exposure to

secondhand smoke damage the interior
walls of arteries including arteries to your
heart allowing deposits of cholesterol to
collect and block blood flow.
Diabetes

Diabetes is the inability of your body to produce or

respond to insulin properly.
Insulin, a hormone secreted by your pancreas,
allows your body to use glucose, which is a form of
sugar from foods.
Diabetes greatly increases the risk of coronary
artery disease, which leads to angina and heart
attacks by speeding up atherosclerosis and
increasing your cholesterol levels
High blood pressure

Blood pressure is determined by the amount of

blood your heart pumps and the amount of
resistance to blood flow in your arteries.
Over time, high blood pressure damages arteries
by accelerating atherosclerosis.
High blood pressure can be an inherited problem.
The risk of high blood pressure increases as you
age, but the main causes are eating a diet too high
in salt, stress, inadequate exercise and being
overweight.
High blood cholesterol or triglyceride
levels
Cholesterol is a major part of the deposits that can narrow
arteries throughout your body, including those that supply
your heart. A high level of the wrong kind of cholesterol in
your blood increases your risk of angina and heart attacks.
Low-density lipoprotein (LDL) cholesterol (the "bad"
cholesterol) is most likely to narrow arteries.
A high LDL level is undesirable and is often a byproduct of
a diet high in saturated fats and cholesterol.
A high level of triglycerides, a type of blood fat related to
your diet, also is undesirable.
However, a high level of high-density lipoprotein (HDL)
cholesterol (the "good" cholesterol) is desirable and lowers
your risk of angina and heart attacks.
Personal or family history of heart
disease
If you have coronary artery disease or if you've had a
heart attack, you're at a greater risk of developing
angina.
Older age. Men older than 45 and women older
than 55 have a greater risk than younger adults.
Lack of exercise. An inactive lifestyle contributes
to high blood cholesterol levels and obesity. Exercise
is beneficial in lowering high blood pressure.
However, it is important to consult with your doctor
before starting an exercise program.
 Obesity

Obesity raises the risk of angina and heart

disease because it's associated with high
blood cholesterol levels, high blood pressure
and diabetes.
Also, your heart has to work harder to
supply blood to the excess tissue.
 Stress

*You may respond to stress in ways that can

increase your risk of angina and heart
attacks.
If you're under stress, you may overeat or
smoke from nervous tension.
Too much stress, as well as anger, can also
raise your blood pressure.
Surges of hormones produced during stress
can narrow your arteries and worsen angina.
Diagnosis
of Angina
Pectoris
History

The typical patient with angina is a man

>50 years or a woman > 60 years who
complains of chest discomfort, usually
described as heaviness, pressure,
squeezing, smothering, or choking and
only rarely as frank pain.
History

When the patient is asked to localize the sensation,

he/she will typically press on the sternum,
sometimes with a clenched fist, to indicate a
squeezing, central, substernal discomfort ( Levines
sign)
The angina is usually crescendo decrescendo in
nature and usually lasts 2 5 mins and can radiate
to the left shoulder and to both arms, especially to
the ulnar surface of the forearm and hand.
History

It can also radiate to the back,

interscapular region, root of the neck, jaw,
teeth, and epigastrium.
Angina rarely localize below the umbilicus
or above the mandible.
History

Although episodes of angina are typically

caused by exertion or emotion and are
relieved by rest, they may also occur at rest
and at night while the patient is recumbent.
The patient may be awakened at night
distressed by typical chest discomfort and
dyspnea.
History

The threshold for the development of angina

pectoris may vary by time of day and
emotional state.
Many patients report fixed threshold for
angina, which occurs predictably at a certain
level of activity, such as climbing two flights
of stairs at a normal pace.
History

Angina may also be precipitated by unfamiliar

tasks, a heavy meal, exposure to cold, or a
combination.
It is also important to uncover family history of
Ischemic Heart Disease and presence of diabetes
mellitus, hyperlipidemia, hypertension, and
cigarette smoking.
The history of typical angina pectoris establishes
the diagnosis of Ischemic Heart Disease until
proven otherwise.
Physical Examination

This is often normal in patients with stable

angina, but it may reveal evidence of
atherosclerotic disease at other sites, such as
an abdominal aortic aneurysm, carotid
arterial bruits, and diminished arterial pulse
in the lower extremities.
There may also be signs of anemia, thyroid
disease, and nicotine stains on the fingertips
from cigarette smoking.
Physical Examination

Palpation may reveal cardiac enlargement

and abnormal contraction of the cardiac
impulse.
Auscultation can uncover arterial bruits, a
third or fourth heart sound, and if acute
ischemia or previous infarction has impaired
papillary muscle function, an atypical
systolic murmur due to mitral regurgitation
Physical Diagnosis

Examination during and anginal attack is

useful, since ischemia can cause transient
left ventricular failure with the appearance
of a third or fourth heart sound, a dyskinetic
cardiac apex, mitral regurgitation and even
pulmonary edema.
Tenderness of the chest wall or reproduction
of pain with palpation of the chest
discomfort makes it unlikely that it is caused
by angina.
Laboratory Examination

The urine should be examined for evidence

of diabetes mellitus and renal disease
(including microalbuminuria) since these
conditions accelerate atheroschlerosis.
Similarly examination of the blood should
include measurements of lipids (total
cholesterol, LDL, HDL, and triglycerides),
glucose, creatinine, hematocrit and thyroid
function.
Laboratory Examination

A chest x-ray is important, since it may

show the consequences of IHD like
cardiac enlargement, ventricular
aneurysm, or signs of heart failure.
These signs support the diagnosis of
IHD and are important in assessing the
degree of cardiac damage.
Chest X-ray findings:
Electrocardiogram
A 12 lead ECG recorded at rest is normal in about
half of the patients with typical angina pectoris, but
there may be signs of an old myocardial infarction.
Repolarization abnormalities like ST segments
and T- wave changes as well as intraventricular
hypertrophy and intraventricular conduction
disturbances, are suggestive of IHD, but they are
nonspecific, since they can also occur at
pericardial, myocardial and valvular heart disease.
Electrocardiogram

Typical ST segment and T wave

changes that accompany episodes of
angina pectoris and disappear
thereafter are more specific.
Stress Testing

The most widely used test for both the

diagnosis of IHD and estimating the
prognosis involves recording the 12 lead
ECG before, during, and after exercise,
usually on a treadmill.
The test consists of a standardized
incremental increase in external workload
while the symptoms, ECG, and arm blood
pressure are monitored.
Stress
test
Stress Testing

Performance is usually symptom limited,

and the test is discontinued upon evidence
of chest discomfort, severe shortness of
breath, dizziness, severe fatigue, ST
segment depression, a fall in systolic blood
pressure or the development of ventricular
tachyarrythmia.
Stress Testing

This test seeks to discover any limitation in

exercise performance, to detect typical ECG
signs of myocardial ischemia, and to
establish their relationship to chest
discomfort.
When interpreting ECG stress tests, the
probability that coronary artery disease
(CAD) exists in the patient should be
considered.
Stress Testing

Overall, false positive or false negative

results occur in one third of cases.
However a positive result on exercise
indicates that the likelihood of CAD is 98%
in males >50 years with a history of typical
angina pectoris and who develop chest
discomfort during the test.
Stress Testing

It is increased in patients taking cardioactive drugs

such as digitalis and quinidine, or in those with
intraventricular conduction disturbances, resting ST
segment and T wave abnormalities, ventricular
hypertrophyor abnormal serum potassium levels.
Since the overall sensitivity of exercise stress
electrocardiography is only 75%, a negative result
does not exclude CAD, although it makes the
likelihood of three vessel or left main CAD
extremely unlikely.
Cardiac Imaging

The imaging is carried out both

immediately after cessation of exercise
to detect regional ischemia and 4 h
later to confirm reversible ischemia and
regions of persistent absent uptake that
signify infarction
Cardiac Catheterization Laboratory
Coronary
Angiogram

Employs
Contrast Media
via Moving
Radiography
Cardiac Imaging

Two dimensional echocardiography can

asses both global and regional wall motion
abnormalities of the left ventricle due to
myocardial infarction or persistent ischemia.
Stress echocardiography may cause the
emergence of regions of akinesis or
dyskinesis not present at rest.
Cardiac Imaging

Echocardiography or radionuclide
angiography should be carried out to
asses left ventricular function in
patients with chronic stable angina and
in patients with a history of a prior
myocardial infarction, pathologic Q
waves or clinical evidence of heart
failure.
2- D Echo
Coronary Arteriography

This diagnostic method outlines the

lumina of the coronary arteries and can
be used to detect or exclude serious
coronary obstruction. However,
coronary arteriography provides no
information regarding the arterial wall,
and severe atherosclerosis that does not
encroach on the lumen may go
undetected
Coronary Arteriography

Coronary arteriography is indicated in

patients with chronic stable angina pectoris who
are symptomatic despite medical therapy and
who are being considered for revascularization
patients with troublesome symptoms that
present diagnostic difficulties in whom there is
need to confirm or rule out the diagnosis of IHD.
Patients with known or possible angina pectoris
who have survived cardiac arrest
Coronary Arteriography

Coronary arteriography is indicated in

Patients with angina or evidence of ischemia on
noninvasive testing with clinical or laboratory
evidence of ventricular dysfunction
Patients judged to be at high risk of sustaining
coronary events based on signs of severe
ischemia on noninvasive testing, regardless of
the presence or severity of symptoms.
Complications
of Angina
Pectoris
 Complications

Cardiac arrhythmias
Ventricular tachycardia
Heart block
Atrial fibrillation
Congestive heart failure
Myocardial infarction
Dresslers syndrome
Mitral regurgitation
Pericarditis
Pulmonary embolism
Shock
Stroke
Sudden death
Ventricular aneurysm
 Cardiac arrhythmia

Abnormal heart rate/ rhythm

Any abnormality or disturbance in the impulse can
result in arrhythmia
 Congestive Heart Failure

Hearts function as a pump is inadequate to meet the

bodys need
May affect the left ventricle, right ventricle or both
 Myocardial Infarction

Occurs when a blood clot completely obstructs an

artery supplying blood to the heart
Dresslers Syndrome-complication that can occur after
a heart attack
-inflammation of the pericardium that is thought to
be an autoimmune disease
-chest pain worsens with leaning forward or taking a
deep breath
 Mitral Regurgitation-backflow of blood from the left
ventricle to the left atrium due to mitral insufficiency
from incomplete closure of the mitral valve
Pericarditis-inflammation of the sac surrounding the
heart
-mostly caused by viral infection
-chest pain worsens with movement and taking a
deep breath
 Pulmonary embolism

Pulmonary embolism
-obstruction of the pulmonary artery or branch of it
leading to the lung by a blood clot that breaks off
-prevents blood from reaching the lung
Shock- life threatening condition that prevents the
heart and bloodstream from delivering enough
oxygen to keep up with the demand of the body
 Stroke- sudden onset focal neurologic deficit
Sudden death
Ventricular aneurysm- bulging in the ventricle of the
heart
 Prognosis

Principal prognostic indicators in Patients with IHD

functional state of the left ventricle
Location and severity of coronary artery narrowing
Severity of myocardial ischemia
Increased risk for adverse coronary events

Angina pectoris of recent onset

Unstable angina
Angina unresponsive / poorly responsive to therapy
accompanied by symptoms of CHF
Most importantly,
Signs during noninvasive testing
Strongly positive exercise test showing onset of
myocardial ischemia at low workloads before
completion of stage II (Bruce Protocol) exercise test
Decline in systolic pressure >10mmHg during exercise
Development of large /multiple perfusion defects or
increased lung uptake during stress radioisotope
perfusion imaging
 -decrease in left ventricular ejection fraction during
exercise on radionuclide ventriculography or during
stress echocardiography
Cardiac catheterization
-elevation in left ventricular end diastolic pressure
and ventricular volume
-reduced ejection fraction
 Excellent prognosis- patient with chest discomfort but
normal left ventricular function
Obstructive lesion of the left anterior descending coronary
artery proximal to the origin of 1st septal artery- associated
with greater risk than lesion of the R/L circumflex
Stenosis of left main coronary is associated with mortality
rate of 15%/ year
Stable angina- marker of underlying CHD
Angina Pectoris
Treatment
SELF CARE AT HOME

Stop doing whatever it is that causes the

symptoms
Call for help
Lie down in comfortable position with head
up
Aspirin
Nitroglycerin
Bring to Hospital Emergency department
At the Hospital

IV line
Aspirin (unless taken one)
Oxygen (face mask or canula)
MEDICATIONS
Nitroglycerin
sublingual, transdermal
relieves angina symptoms by expanding blood
vessels and decreasing the muscle's need for
oxygen
taken only when the patient actually has
symptoms or expect to have them.
Slow - or long-acting nitroglycerin can be used as
a preventative treatment for angina but not until
beta blockers are tried first.
 Calcium channel blockers
are used primarily when beta blockers cannot be used
and/or the patient is still having angina with beta blocker
also lower blood pressure and certain ones slow heart
rate.
taken every day

ACE inhibitors
also vasodilators with both symptomatic and
prognostic benefit
 Statins
lower cholesterol and stabilize the fatty plaque on the
inner lining of the coronary artery, even when the blood
cholesterol is normal or minimally increased.
Low density lipoprotein (LDL) levels should be less than
70 mg/dL for those at high risk of heart disease.

Beta blockers:
lessen the heart's workload
slow the heart rate, decrease blood pressure, and lessen
the force of contraction of the heart muscle, this
decreases the heart's need for oxygen and thus decreases
angina symptoms
Beta blockers are taken every day, regardless of whether
the patient is having symptoms, because they are proven
to prevent heart attacks and sudden death.
Heparin medications
enoxaparin (Lovenox), dalteparin (Fragmin), and
nadroparin (Fraxiparin)
Frequent blood tests are needed to monitor the
concentration of heparin in the blood.
IIb/IIIa inhibitors
eptifibatide (Integrelin), tirofiban (Aggrastat), and
abciximab (ReoPro).
almost completely prevent the formation of blood clots and
may help dissolve existing blood clots.
Adding these agents to standard treatment regimens for
unstable angina may reduce the risk for unstable angina
progressing to heart attack.
Warfarin (Coumadin)
anticoagulant that is prescribed for patients who have a
history of or are at risk for formation of blood clots
(thrombosis)
Aspirin
Daily aspirin therapy is mandatory to decrease the
possibility of sticky platelets in the blood starting a blood clot
Clopedigrol (Plavix)
slightly more potent than aspirin, is considered a long-term
alternative to aspirin therapy. Clopedigrol is usually taken in
a dose of one 75 mg tablet daily
Heparin medications
enoxaparin (Lovenox), dalteparin (Fragmin), and
nadroparin (Fraxiparin)
Frequent blood tests are needed to monitor the
concentration of heparin in the blood.
IIb/IIIa inhibitors
eptifibatide (Integrelin), tirofiban (Aggrastat), and
abciximab (ReoPro).
almost completely prevent the formation of blood clots and
may help dissolve existing blood clots.
Adding these agents to standard treatment regimens for
unstable angina may reduce the risk for unstable angina
progressing to heart attack.
 Warfarin (Coumadin)
anticoagulant that is prescribed for patients who have a
history of or are at risk for formation of blood clots
(thrombosis)
Miscellaneous anti-anginal drugs
In 2006, the FDA approved ranolazine (Ranexa). Because of its
side effects (potential to cause abnormal heart rhythm), is
indicated only after other conventional drug treatments are
found to be ineffective
If inhibitor
ivabradine
provides pure heart rate reduction leading to major anti-
ischemic and antianginal efficacy.
Zinc supplementation
Surgery
Percutaneous Transluminal Coronary Angioplasty
PTCA, angioplasty, balloon dilation or balloon angioplasty
coronary arteriography
a thin, flexible plastic tube (catheter) with a balloon is inserted into
an artery in the arm or groin with local sedation and advanced to the
blockage. Then the balloon is inflated, squeezing open the fatty
plaque deposit. Then the balloon is deflated and the catheter is
withdrawn. Often a stent, which is a small metal sleeve, is also placed
to hold the artery open.
Coronary Artery Bypass Surgery
chest and rib cage are opened up
The narrowed part of the artery is bypassed by a piece of vein
removed from the leg, or with a piece of artery behind the sternum
(internal mammary artery), or a portion of the radial artery taken
from the lower arm or forearm.
Several arteries can be bypassed in one operation.
Angioplasty
by Stenting
procedure
 Transmyocardial Revascularization
for people who cannot undergo angioplasty or surgery.
simple incision is made in the chest, and a laser is used to
"drill" small holes through the outside wall of the heart
into the left ventricle.
About 20-40 holes are made.
Bleeding from these holes is minimal and usually stops
after a few minutes of pressure.
not clear why this helps relieve angina. One theory is that
it stimulates growth of new blood vessels that improve
blood flow to the heart. Other investigators believe it is a
placebo effect.
Current research is focusing on trying to find growth
factors that could be injected into coronary arteries or
directly into the left ventricle to encourage growth of new
blood vessels
Laser angioplasty
a catheter with a laser on its tip is used to
open the blockage
may be accompanied by stent placement
Atherectomy
a catheter has a rotating shaver on its tip to
cut away the plaque
may be accompanied by stent placement
Enhanced External Counterpulsation (EECP therapy)
with chronic stable angina that is unresponsive to medical
therapy
noninvasive outpatient procedure, it usually is
administered during 35 treatment hours, divided into one
or two 60-minute treatment sessions per day, 5 days per
week.
patient lies on a padded table and adjustable cuffs are
wrapped firmly around the calves, lower thighs, and upper
thighs. These cuffs are connected to inflation and deflation
valves that are controlled by an electrocardiogram. When
the heart rests, the cuffs are inflated sequentially and
rapidly from the lower leg to the upper leg and then are
deflated just before the heart beats. This results in an
increased blood supply to the heart while reducing its
workload.
Prevention
Stop smoking and using nicotine in any form.
Control high blood pressure.
Lower blood fats
Maintain a healthy weight.
Control diabetes and blood sugar
If a person already has atherosclerosis and angina, they can
learn to take precautions to avoid having symptoms.
Avoiding the "triggers"
Do not use caffeine, cocaine, amphetamines, or other
stimulants
Drink alcohol moderately (no more than 1-2 drinks daily)
Avoid large and heavy meals that leave you feeling "stuffed"
Decrease stress
regular exercise routine If the patient has been exercising
strenuously, they may need to cut back to avoid symptoms.
aspirin daily
-The end-