1. ISCHEMIC HEART DISEASE
Afsar fathima
M.Pharm

2. 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.

3. 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

4. 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

5. 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

6. Classification
Classical or stable angina( 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.

7. 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

9. Coronary Artery

10. Pathophysiology

11. Pathophysiology

12. Pathophysiology of MI

13. Pathophysiology of MI

14. 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

16. 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

17. 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.

18. NORMAL ECG
ST segment depression & T Wave Inversion In Myocardial Ischaemia

19. NORMAL ECG
ST segment elevation & T Wave Inversion In Myocardial Infraction

22. 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)

23. Drugs used in myocardial infarction
Oxygen
Morphine. i.v.
Aspirin low dose
Nitroglycerin.SL,
Streptokinase. i.v.
furosemide.i.v.
Propranolol. PO
ACEI
Heparin/or warfarin
Clopidogrel

24. Consequences of Hypertension:
Left Ventricular Hypertrophy
Cerebral Infarction (Stroke)
Heart
Hypertensive cardiomyopathy,
IHD, MI.
Brain:
Hemorrhages
infarction

25. 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

26. Aspirn + Clopidogrel

27. 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.

28. Interactions with nitrates
+sildenafil: contraindicated
+alcohol: sustained fall of BP
+propranolol:
reflex tachycardia suppressed
attenuation of beta blocker induced ventricular dilatation
therapeutic synergy

29. 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