ISCHEMIC
HEART DISEASE
PLAN OF STUDY
1.
2.
3.
4.
5.
6.
7.
8.Investigations
9. Complications
10.DD
11.Management
12. Conclusion
13. Homoeopathic
approach
14. Bibliography
Blood supply
The two coronary arteries, left and right,
arise from the left and right sinus of
Valsalva, respectively. In 10% of
individuals the circulation is considered as
"left dominant" as the circumflex artery
gives off the posterior descending artery.
In 90%, the circulation is right dominant as
the posterior interventricular artery is given
off from the right coronary artery
O2 supply
Blood pressure
Temperature
Inorganic ions
Neuroharmones
DEFINITION OF IHD
The World Health Organisation has
defined ischaemic heart disease (IHD) as
myocardial impairment due to imbalance
between coronary blood flow and
myocardial requirements.
The most common cause of IHD is
atherosclerotic coronary artery
disease[CAD]
Aetiology
MAJOR RISK FACTORS
CONSTITUTIONAL
Age
Sex
Genetic
Familial
Acquired
Hyperlipidaemia
Hypertension
DM
Smoking
Environmental influences
Obesity
Infections
Harmones
Physical inactivity
Stressful life
Role of alcohol
Homocystinuria
PATHOPHYSIOLOGY OF
MYOCARDIAL ISCHAEMIA
Myocardial ischaemia occurs as a result of
imbalance between O2 supply and
demand.
Etiopathogenesis
1.Coronary atherosclerosis:
Distribution:[ SVD, TVD]
Location.
Asymptomatic state
Angina pectoris
Acute myocardial infarction
Chronic ischemic heart disease
Sudden cardiac death
ANGINA
It is derived from the greek word
STRANGULATION.
It is a syndrome SENSE OF BAND
AROUND CHEST. Patient presses his
sternum with clenched fist to locate the
pain.
Progressive constriction of coronary
arteries cardiac pain called angina.
Diurnal
Even sometimes smoking, sexual act,
shaving, straining at stool
Variants:
Start-up or Walk- through angina,
Nocturnal angina,
Decubitius angina,
Post Prandal angina,
Ammunition factories.
Class
Patientshavecardiacdiseasebutwithout
theresultinglimitationsofphysicalactivity.
Ordinaryphysicalactivitydoesnotcause
unduefatigue,palpitation,dyspnea,or
anginalpain.
Ordinaryphysicalactivity,such
aswalkingandclimbingstairs,
does not cause angina.Angina
presentwithstrenuousorrapid
orprolongedexertionatworkor
recreation.
II
III
IV
Patientshavecardiacdiseaseresulting Inabilitytocarryonany
ininabilitytocarryonanyphysical
physicalactivitywithout
activitywithoutdiscomfort.Symptoms discomfortanginal
ofcardiacinsufficiencyoroftheanginal syndromemaybepresent
syndromemaybepresentevenatrest. atrest.
Ifanyphysicalactivityisundertaken,
discomfortisincreased.
INVESTIGATIONS
1. X-ray chest for cardiomegaly or
pulmonary congestion. 2. Lipid profile 3.
Blood sugar, serum uric acid and urine
examination
Electrocardiogram : In 50% of patients
with angina, the resting ECG is normal
between anginal episodes. During an
anginal episode transient ST-T depression
may be noted which disappears with rest
or with sublingual nitroglycerine
Prinzmetal angina
Also called variant angina, it was
described by Prinzmetal in 1959. The pain
usually occurs at rest at night or in the
early morning hours. It is associated with
ST elevation on the ECG, responds to
sublingual nitroglycerine, and is caused by
spasm of the coronary artery.
Unstable angina
Also called intermediate coronary
syndrome and Preinfarction angina, it is a
serious form of angina and needs special
attention since 20% of these patients are
likely to develop fatal or nonfatal
myocardial infarction within 4 months.
There is a higher incidence of left main
coronary artery disease in these patients.
Management
Thrombolytic agents
PTCA
CABG
MYOCARDIAL INFARCTION
The area of muscle that has either zero
flow or so little flow that it cannot sustain
cardiac muscle function process called
Infacrtion.
Etiopathogenesis:
Mechanism of Myocardial ischemia:
Diminished coronary blood flow, Increased
myocardial demand, Hypertrophy of heart
without increase in coronary blood flow.
Transmural
Full thickness
Superimposed thrombus in
atherosclerosis
Focal damage
Sub-endocardial
Inner 1/3 to half of ventricular
wall
Decreased circulating blood
volume( shock, Hypotension,
Lysed thrombus)
Circumferential
Types of infarcts:
1. Acc to anatomical region of left
ventricle: Anterior, lateral, septal,
circumferential or combinations.
2. Acc to degree of thickness : Transmural,
Subendocardial.
3. Acc to age old, new [ healed & fresh].
Location of infarcts:
Infarcts are most frequently located in left
ventricle . Right ventricle is less
susceptible to infarction due to its thin wall
less metabolic requirement.
CLINICAL FEATURES
The presenting symptoms vary from
severe pain in the chest to minimal
symptoms with the disease being
unrecognised. In most patients, there is
substernal pain of varying intensity,
radiating to the arms, jaws or back or the
epigastric region, with sweating. The pain
lasts for 20 minutes or more and is
unrelieved or partially relieved by
sublingual nitroglycerine
C/F
Pain
Indigestion
Apprehension
Shock
Oliguria
Low grade fever
Acute pulmonary oedema
Cardiac reserve
Maximum amount of cardiac output that
can increase above normal. It is 400%
blood per min more than body requires.
INVESTIGATIONS
Leucocytosis with polymorphonuclear
reaction and high ESR due to tissue
necrosis are present during the first week.
MANAGEMENT
Almost 30-35% of patients with AMI die
due to arrhythmias, LV failure and
cardiogenic shock. Half of these deaths
occur in the first 1-2 hours after onset of
symptoms and 70-80% in the first 24
hours. Further, the Time window for
salvaging the ischaemic myocardium at
risk of necrosis is about 6 hours
Reperfusion
An occluding thrombus is responsible for
myocardial infarction in almost 85% of
patients. It is known that the infarction is
completed after several hours. An attempt
should therefore be made to remove the
obstruction and achieve reperfusion to reestablish blood flow to the jeopardised
myocardium and so limit the size of the
infarct.
INDICATIONS OF PTCA:
Coronary arteriography is indicated in (1)
patients with chronic stable angina
pectoris who are severely symptomatic
despite medical therapy and who are
being considered for revascularization,
i.e., a percutaneous coronary intervention
(PCI) or coronary artery bypass grafting
(CABG)
CHRONIC IHD
Ischemic Cardiomyopathy or Diffuse
fibrosis in the myocardium
characterstically found in elderly age
group.CHF is gradually developed
decompensation over a period of years
[Chronic anaemia]
Differential Diagnosis
1. Pericarditis Hours to days; may be
episodic Sharp Retrosternal or toward
cardiac apex; may radiate to left shoulder
May be relieved by sitting up and leaning
forward <cough, swallowing, lying in
leftsided supine.
Pericardial friction rub
Prognosis
Depends on:
1.Number of diseased vessels
2. Degree of LV dysfunction
MANAGEMENT [ADAPTATION]
Myocardial ischemia is caused by a
discrepancy between the demand of the
heart muscle for oxygen and the ability of
the coronary circulation to meet this
demand. Most patients can be helped to
understand this concept and utilize it in
the rational programming of activity.
EXERCISES
A regular program of isotonic exercise
[muscles contract & there is movement]
that is within the limits of each patient's
threshold for the development of angina
pectoris and does not exceed 80% of the
heart rate associated with ischemia on
exercise testing should be strongly
encouraged.
Avoid Isometric exercises[muscle
contract increase in tension but does not
move]
CONCLUSION
Chest discomfort is one of the most
common challenges for clinicians in the
office or emergency department. The
differential diagnosis includes conditions
affecting organs throughout the thorax and
abdomen, with prognostic implications that
vary from benign to life-threatening.
Homoeopathic approach
Physiological action basis said by
Dr.Richard Hughes:
Aconite: In all diseases of heart
characterised by increased action when
leftside is chiefly
involved.[ Physiologically cardiac
depressent][ Fear, anxiety, mental
restlessness]
Dr. Clark: Rapidity of action relieved
sometimes so painful & distressing spasm
BIBLIOGRAPHY
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