ISCHEMIC HEART DISEASE Afsar fathima - PowerPoint Presentation

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ISCHEMIC HEART DISEASE

Afsar fathima

M.Pharm

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ANGINA PECTORIS

Angina pectoris is a clinical syndrome of chest discomfort caused by reversible myocardial ischemia that produces disturbances in myocardial function without causing myocardial necrosis.

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Suffocating substernal pain in the chest, over the heart, on exertion which may radiate to left arm , neck of the jaw, and is relieved by rest

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EPIDEMIOLOGY

incidence rate - 1.5%

Cardiovascular diseases (CVD) claimed 949,619 lives

1 of every 2.5 deaths, in the United States in 1998.

four to five times more common in men in their mid-30s

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Reasons & risk factors

Coronary artery spasm

Partial coronary thrombosis

Abnormal endothelial functions

Stress variation in blood pressure

Impairment in NO production

Risk factors; Anemia, hypertension, acute & chronic anxiety,

thyrotoxicosis

, obesity, heart failure

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Classification

Classical or stable angin

a( angina of effort or

exertional

angina)

Atherosclerosis of larger coronary arteries

Cresendo

or unstable angina

(

Preinfraction

angina)

Recurrent attacks of angina

Results from combination of atherosclerotic plaques, platelet aggregation at ruptured plaque & vasospasm.

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Variant or

prinzmetal

angina

(

Vasospastic

angina)

Pain appears even during rest or during sleep & is usually unrelated to

exercis

recurrent localized coronary vasospasm

Silent Myocardial Ischemia

With out producing

anginal

pain

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Coronary Artery

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Pathophysiology

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Pathophysiology

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Pathophysiology of MI

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Pathophysiology of MI

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Pathophysiology

Angina Pectoris is mainly due to diminished coronary perfusion relative to the myocardial demand because of narrowing of the

epicardial

coronary arteries,

intraluminal

thrombosis, platelet aggregation and vasospasm

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C L I N I C A L PRESENTATION OF ANGINA

SYMPTOMS

Sensation of pressure or burning over the sternum or near it, often but not always radiating to the left jaw, shoulder, and arm; also, chest tightness and shortness of breath.

Pain usually lasting from 0.5 to 30 minutes, often with a visceral quality (deep location).

Precipitating factors include exercise, cold environment, walking after a meal, emotional upset, fright, anger, and coitus.

Relief occurs with rest and nitroglycerin.

SIGNS

Abnormal heart sounds

 

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LABORATORY TESTS

Typically, no laboratory tests are abnormal;

however, if the patient has intermediate- to high-risk features for unstable angina, electrocardiographic changes are seen, and serum

troponin

or

creatine

kinase

concentrations may become abnormal

 

Hemoglobin should be checked to make sure that the patient is not anemic.

OTHER DIAGNOSTIC TESTS

A resting electrocardiogram (ECG) followed by an exercise tolerance test usually are the first tests done in stable patients.

A chest x-ray should be done if the patient has heart failure symptoms.

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NORMAL ECG

ST segment depression & T Wave Inversion In Myocardial

Ischaemia

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NORMAL ECG

ST segment elevation & T Wave Inversion In Myocardial Infraction

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PHARMACOLOGIC THERAPY

Organic Nitrite and Nitrates:-

amyl nitrite, nitroglycerin,

Isosorbide

dinitrate

Isosorbide

-5-

mononitrate

Erythrityl

tetranitrate

Pentrerythrityl

trinitrate

β-Adrenergic Receptor Blockers:-

Propranolol

Metoprolol

,

Atenolol

,

Sotalol

,

Nodalol

,

Acebutolol

,

Pindolol

.

Calcium Channel Blockers:

Nifedipine

,

Diltazem

,

Verapamil

,

Nicardipine

Miscellaneous coronary vasodilators:

Potassium Channel Openers -

Nicorandil

,

Cytoprotective

Drugs -

Trimetazidine

Antiplatelet

Drugs

Low dose Aspirin,

Clopidogrel

Statins

(plaque stabilization)

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Drugs used in myocardial infarction

OxygenMorphine. i.v.Aspirin low doseNitroglycerin.SL, Streptokinase. i.v.furosemide.i.v.Propranolol. POACEI

Heparin/or

warfarin

Clopidogrel

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Consequences of Hypertension:

Left Ventricular Hypertrophy

Heart

Hypertensive cardiomyopathy,

IHD, MI

.

Cerebral Infarction (Stroke)

Brain

:

Hemorrhages

infarction

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Aim of the treatment

Depends on clinical type

Symptomatic management of acute episode

Anti-thrombotic therapy to prevent progression to MI

Long term management

Prevent attack & reduce the risk of other cardiovascular events

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Aspirn + Clopidogrel

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Anti anginal drugs- nitrates

Nitrates increase 02 supply & decrease demand. reduce myocardial work- decrease pre & after load

Vasodilator &

venodilator

.

Reduce left ventricular diastolic volume & pressure

.

Routes: SL, PO &

i.v

.

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Interactions with nitrates

+sildenafil: contraindicated

+alcohol: sustained fall of BP

+propranolol:

reflex tachycardia suppressed

attenuation of beta blocker induced ventricular dilatation

therapeutic synergy

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Beta blockers in angina-rationale

HR is reduced

Myocardial contractility is decreased

High blood pressure declines

Cardiac arrhythmias control

Reduce myocardial 02 requirement

not for

Prinzmetal’s

, RSP disorders,

bradyarrhythmias

& CCF

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