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Ischaemic heart disease

Intro

This is a severe condition where the heart isn’t recieving enough blood meet needs. This is usually due to something occluding coronary vessels partially or totally. There are multiple clinical manifestations of this:

  • Angina: Partial occlusion can present as angina which is heart pain on exertion, this happens because exertion heightens blood demand of the heart higher than the coronary vessels can supply. This is called stable angina, as it is exercise induced and is relieved by rest. Contrast this with unstable angina.
  • Unstable angina: This is a sudden thrombus forming in the coronary vessels due to a ruptured plaque. Unstable angina can lead to a myocardial infarction if it isn’t cleared.
  • Myocardial infarction: is when there is complete occlusion of a coronary artery that leads to ischaemia in the heart. These are life threatening and need immediate treatment. This can lead to lasting damage in the heart which can contribute to Chronic Heart Failure
  • Prinzmetals angina: (Variant Angina) can occurs in younger people and it is vasospasm of coronary arteries, restricting blood to the heart.

Causes

These conditions are often because of Coronary artery disease, where atherosclerotic plaques builds in the heart, occluding arteries.

Stable Angina

Stable angina is a condition where plaques build in the heart enough to where exertion (which increases blood demand from the heart), pushes demand higher then what is able to be delivered.

Clinical signs and symptoms

Clinical signs and symptoms of stable angina are:

Symptoms:

  • exercise induced chest pain

Tests

  • ECG on exercise to look for ischaemia

Complications

Increasing of severity of CAD can lead to more serious angina, unstable angina and MI Serious angina can lead to lasting ischaemic damage to the heart

Management

Use sublingual GTN spray for breakthrough angina and classic management of CAD which is:

Acute coronary syndrome

This is a condition which is complete occlusion (or occlusion over 70% of the diameter of the coronary vessel), leading to ischaemia.

Unstable angina

This is often due to a plaque rupture, when an atherosclerotic plaque ruptures, causing a thrombus and occluding the coronary vessel. This can progress to a Myocardial Infarction. This occurs independently of exertion.

Symptoms:

  • Sudden chest pain that doesn’t go away
  • Radiating pain to the neck jaw and down the left arm.
  • Paleness
  • Cold sweats
  • Nausea
  • Vomiting
  • Shortness of breath
  • Dizziness
  • Racing heart

Signs:

Monitor ECG for possible St elevation

Complications

Can lead to Myocardial infarction if occlusion completely blocks the coronary vessel

Management

Treat for MI And possible sublingual GTN to try to ease symptoms

Myocardial infarction

This is when a blockage of a coronary vessel leads to ischaemia of the myocardial tissue. Can be NSTEMI or STEMI depending on if there is presence of ST elevation, If there is St elevation it is a STEMI and it means a far larger portion of the myocardial wall is damaged

Symptoms:

  • Sudden chest pain that doesn’t go away
  • Radiating pain to the neck jaw and down the left arm.
  • Paleness
  • Cold sweats
  • Nausea
  • Vomiting
  • Shortness of breath
  • Dizziness

Signs:

  • Possible ST elevation of ECG: this can show severity of hear attack,
  • Troponin-T levels in blood test: this is a protein in the heart which can show up in blood tests if the cardiomyocytes are damaged
  • CK-MB levels in blood test: see above

Complications

  • Acute Heart failure leading to death: the heart goes into cardiac arrest and does not pump blood, leading to cardiogenic shock and death
  • Chronic heart failure: The scarring from the ischaemic necrosis can accelerate heart failure

Management

Acute

  • Morphine for pain
  • Thrombolytics (to break the clot)
  • Percutaneous intervention (placing a balloon)

Prevent complications

  • Place a stent
  • High grade anticoagulation

Management

  • Anticoagulants, Antiplatelets
  • Manage HTN if present
  • Cholesterol management: Statins
  • if needed: inotropic drugs (heart failure), b blocker (not for heart failure), anti arrhythmic if arrthymia develops

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