Ischaemic heart disease

Sudden Cardiac Death

Death d/t cardiac causes which occurs w/in 6
hours o onset o symptoms.

Angina
Dx by clinical hx
Nha 0813 – source Kumar & Clark - Oxford
 During  Transient ST
S&S attack depression
Chest pain ‘tight’,’heavy’,’gripping’  T-wave
Central/retrosternal inversion
Radiates to jaws/arm  ∆ T shape
Ass. sym Sweatiness Evidence  Old MI
Palpitation of  LBBB
SOB  Lf ventricular
hyperT
Classical/ Provoked by : Exercise  Confirm dx
exertional  Physical exertion ECG  Severity of CAD
angina  Aftr meal  ST depression ≥ 1mm →
pectoris  Windy & cold weather myocardial ischaemia
 Anger or excitement Echocardiography Assess ventricular wall
 Chest pain relieve by rest involvement & ventricular
Decubitus  Occur on lying down fx
angina  a/w impaired lf ventricular Coronary  In px w chest pain w
fx d/t severe coronary art angiography unclear dx
dz  To delineate exact
Nocturnal  At nite & wake px coronary anatomy
angina  In px w critical coronary Cardiac scintigraphy
art dz
Variant  Angina occur w/out
(Prinzmetal’s) provocation
angina  Occur at rest
 d/t coronary art spasm
 ST elevation during pain
 Dx by provocation test
Unstable Angina of :
angina  Recent onset (< 1/12)
 Worsening angina
 Angina at rest

PE & DX Tx :
Should exclude any sx of : General
Anaemia Tx underlying prob  Anaemia
Thyrotoxicosis  Hyperthyroidism
Hyperlipidaemia Possible cause of Mx underlying cond  DM
Aortic stenosis angina  HPT
 Slow-rising Medical theraphy
carotid impulse Prognostic theraphy Symptomatic tx
 Ejection sys  Aspirin  GTN
murmur  Lipid lowering  Beta blockers
Take BP Coexistent HPT? theraphy  Long acting
nitrates
 Ca channel
blocker
 Nicorandil
Revascularization
Coronary artery Angioplasty
bypass grafting
Ix
Resting ECG Norm btwn attack Acute Coronary Syndrome
Nha 0813 – source Kumar & Clark - Oxford
  Pallor
Involve :  pulse↑ or↓
1. ST-elevation MI (STEMI)  BP ↑ or↓
2. Non ST-elevation MI (NSTEMI)  4th heart sound
3. Unstable angina  Sx o  failure
- ↑JVP
Pathophysio
- 3rd  sound
- Basal crepitation
 Pansys murmur
- Papillary muscle
dysfx or rupture
- VSD
 ↓ grade pyrexia
 Later
- Pericardial friction
rub
- Peripheral edema
Electrocardiogram
Findings  Normal
 ST depression
 T wave inversion
STEMI  ST elevation
 LBBB pattern
Prinzmetal angina  Transient ST
elevation
recommended  Repeat ECG during
pain
 Continuous ECG
monitoring
Diagnosis Biochem markers
Clinical presentation CK MB
Chest pain  New onset Cardiac troponin  Cardiac specific
 Deteriotation o pre- troponin I & T →
existing angina myocyte necrosis
 > 20 mins  If initial troponin assay
Ass symp  Nausea -ve→ repeat 9-12 hr
 Sweatiness aftr admission
 Dyspnea Myoglobin  Rapid dx o ACS
 Palpitation  ↑ very early in course o
Atypical features  Indigestion MI
 Pleuritic chest pain
 Dyspnoea Other test:
PE exclude ddx  Aortic dissection CXR  Cardiomegaly
 Pulmonary embolism  Pulmonary edema
 Peptic ulcer  Wide mediastinum
 (aortic dissection)
Blood  FBC
 U&E
 gluc↑
 lipids ↓
 cardiac enzyme
Signs  Distress
 Anxiety

Nha 0813 – source Kumar & Clark - Oxford

Ddx
1. Angina
2. Pericarditis
3. Myocarditis
4. Aortic dissection
5. Pulmonary embolism
6. Esophageal reflux/spasm

Risk stratification :
Criteria for ↑ & ↓risk for death or MI
↑ ↓
 Px w ECG abnorm  X recurrence o
 Dynamic ST ∆ chest pain w/in
>0.05 mV xpeciali observe period
ST depression  w/out x ST
 T wave inversion > depression/
0.2 mV elevation but –
 Patho Q wave ve T wave, flat T
 BBB wave or norm
 Sustained ECG
ventricular tachy  w/out elevation
 Px w ↑ troponin o troponin or
level other
 Px w lf ventricular biomarkers
dysfx or LV ejection
fraction < 40%

MX

Algorithm for ACS mx :

Beta blocker C/I in px w :

1. asthma
2. COPD
3. LVF
4. Bradycardia
5. Coronary artery spasm

Acute mx o ACS w/out ST elevation :

Nha 0813 – source Kumar & Clark - Oxford