1. Ischemic Heart Disease (IHD – coronary Heart Disease)
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box – Riyadh 11417
Tel: – Fax: 1

2. objectives: At the end of this session the trainee will be able to
be able to discuss the burden of IHD.
describe essential elements in history taking & examination
develop a differential diagnosis of chest pain.
describe appropriate diagnostic testing for chest pain.
discuss modifiable & non modifiable risk factors for cardiac disease.
describe the use of investigation in the evaluation of a patient with chest pain.
appropriatly use of specialty referral.

3. Prevalence of IHD
Heart diseases responsible for overal deaths in the Saudi population:
IHD : 17%
Hypertensive heart disease 9%
CVA : 4%
18th scientific session of the Saudi Heart Association

4. History taking in CAD
Patient characteristics (Name, age, sex,occupation)
Pain (duration, location, intensity,nature,aggravating factors
Associated symptoms (Dyspnea, syncope….etc)
Past history (HPN,DM,COPD..ETC)
Family history (coronary artery disease ,pneumothorax)
Drug history (antiangina,anti diabetic..etc)
Life style (Diet, exercise, alcohol, smoking )
Psychosocial (ICE, anxiety, stress )

5. What characteristics of the chest pain might make you more concerned for cardiac chest pain?
Location
Associated Symptoms
Quality
Chronology
Onset
Duration
Intensity
Exacerbating
Relieving
Situation

6. Physical Examination General Examination
patient status: stable,notstable,inpain or not in pain.
Vital signs.
Obese or overweight.
Skin appearance.
Cardiovascular &respiratory system examination
BP, Pulse rate, JVP.
Chest :apex beat deviation, crepitations, decrease breath sounds.
Heart : 1st & 2nd heart sounds, gallop, friction rub.
Abdomen: tenderness, guadring….

7. Any exam findings that might help distinguish cardiac from non cardiac chest pain?
General Appearance
may suggest seriousness of symptoms.
Vital signs
marked difference in blood pressure between arms suggests aortic dissection
Palpate the chest wall
Hyperesthesia may be due to herpes zoster
Complete cardiac examination
pericardial rub
Ischemia may result in MI murmur, S4 or S3
Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

8. What would be the differential diagnosis for chest pain?

9. Life threatening Causes Non-life threatening Causes
Cardiovascular(16%):
Myocardial infarct.
Angina.
Thoracic aortic dissection.
Pulmonary (5%):
Pulmonary embolus.
Pulmonary infarction.
Tension pneumothorax.
Pneumonia.
Pleurisy.
Chest wall (33%):
Trauma
Fracture
Costo-chondritis.
Musculoskeletal.
Gastrointistinal(20%):
Esophageal spasm
Esophagitis.
Gall bladder disease.
Peptic ulcer disease.
pancreatitis
Psychatric (9%):
Anxiety.
Spinal dysfunction:
Cervical disease.
Infections (rare):
Herpes Zoster. ..

10. The risk factors for CAD
Age > 45 (male) and >55 (female).
Smoking.
Family history.
Hyperlipidemia.
Diabetes.
Hypertension.
Obesity.
Sedentary life style.
Anxiety.
Drug addiction.
Past History.

11. Any tests that might help in diagnosis?
History and Examination
ECG
Cardiac Enzymes
Chest x-ray.
Upper GI endoscopy.

12. Cont… ECG ST elevation of > 1mm or new Q in 2 leads
Sensitivity 45%
Above + ST depression or T-wave inversion
Sensitivity 79%
False positive rate = 17%
20% of patients having an MI will have a normal ECG initally

13. Cont… Cardiac enzymes: Troponin, CK, myoglobin
88-90% sensitive at 4-6 hours
95-100% sensitive 8-12 hours
Source: Am Heart J Aug;136(2):237-44

15. LDL Level at Which to Consider Drug Therapy (mg/dL)
Risk Category
LDL Goal (mg/dL)
LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)
LDL Level at Which to Consider Drug Therapy (mg/dL)
CHD or CHD Risk Equivalents (10-year risk >20%)
Very high risk
<100
<70 (VHRP)
100
130 (100–129: drug optional)
(< 100: drug optional)
2+ Risk Factors (10-year risk 20%)
(moderately high risk pt )
10-year risk < 10%
<130
<100(theraputic option)
130
10-year risk 10–20%: 130
10-year risk <10%: 160
0–1 Risk Factor
<160
160
190 (160–189: LDL-lowering drug optional)

16. Diabetes is regarded as a CHD Risk Equivalent
10-year risk for CHD  20%
High mortality with established CHD
High mortality with acute MI
High mortality post acute MI

17. Initial Approach ABC assessment 100% Oxygen Aspirine Nitroglycerine
IV access
Morphine
Monitoring
ECG quickly
MONA
Morphine
Oxygen
Nitroglycerine
Aspirine

18. Action Plan

19. Action Plan
Source:

20. Referral Refer urgently all the serious conditions with chest pain:
Cardiac causes.
Esophageal spasm.
Pulmonary embolism.
Any other cases not responding to usual treatment.

21. Important Points
The likelihood of acute coronary syndrome (low, intermediate, high) should be determined in all patients who present with chest pain.
A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain.
Cardiac markers (troponin T, troponin I, and/or creatine kinase-MB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome.

22. Important Points
A normal electrocardiogram does not rule out acute coronary syndrome.
When used by trained physicians, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (a computerized, decision-making program built into the electrocardiogram machine) results in a significant reduction in hospital admissions of patients who do not have acute coronary syndrome.