1. Ischaemic Heart Disease

2. Aims and Objectives n Ischaemic heart disease –Definition, manifestations, epidemiology, aetiology, pathophysiology, risk factors and prevention n Chest pain –Differential diagnosis n Acute myocardial infarction –Assessment, treatment, complications n Cardiopulmonary resuscitation

3. Ischaemic heart disease Definition

4. n An imbalance between the supply of oxygen and the myocardial demand resulting in myocardial ischaemia. n Angina pectoris symptom not a disease chest discomfort associated with abnormal myocardial function in the absence of myocardial necrosis

5. Ischaemic heart disease Definition n Supply –Atheroma, thrombosis, spasm, embolus n Demand –Anaemia, hypertension, high cardiac output (thyrotoxicosis, myocardial hypertrophy)

6. Ischaemic heart disease Manifestations n Sudden death n Myocardial infarction n Acute coronary syndrome n Stable angina pectoris n Heart failure n Arrhythmia n Asymptomatic

7. Ischaemic heart disease Aetiology n Fixed –Age, Male, +ve family history n Modifiable – strong association –Dyslipidaemia, smoking, diabetes mellitus, obesity, hypertension n Modifiable - weak association –Lack of exercise, high alcohol consumption Atherosclerosis

8. Ischaemic heart disease Pathophysiology

9. n Response to injury hypothesis n ATHEROSIS Accumulation of cholesterol within the vessel wall intima. Smooth muscle cell proliferation n SCLEROSIS Expansion of fibrous tissue n INFLAMMATION Chronic inflammatory cells migrate into wall, release cytokines n GROWTH FACTORS/INFLAMMATORY MEDIATORS

10. Ischaemic heart disease Pathophysiology

11. Ischaemic heart disease Acute coronary syndromes Atherosclerosis Fatal / non-fatal AMI Unstable angina Coronary Artery spasm

12. Ischaemic heart disease Acute coronary syndromes n Fatal AMI Small, fat rich plaques. Plaque RUPTURE. Thrombus in lipid core and on plaques surface. Vessel lumen OCCLUDED. n Non-fatal AMI Plaque EROSION rather than rupture. OCCLUSIVE thrombus. n Unstable angina Usually mod-severe stenosis. Multiple vessels. Collaterals often formed. Thrombus formation and vasoconstriction. Myocardial infarction may ensue.

13. Ischaemic heart disease Risk factors and prevention n Family History n Smoking n Hypertension n Diabetes Mellitus n Hypercholesterolaemia n Lack of exercise n PRIMARY PREVENTION

14. Chest Pain Myocardial ischaemia n Site Jaw to navel, retrosternal, left submammary n Radiation Left chest, left arm, jaw….mandible, teeth, palate n Quality/severity tightness, heaviness, compression

15. Chest Pain Myocardial ischaemia n Precipitating/relieving factors physical exertion, cold windy weather, emotion rest, sublingual nitrates n Autonomic symptoms sweating, pallor, peripheral vasoconstriction, nausea and vomiting

16. Acute Myocardial Infarction

17. Acute Myocardial Infarction Assessment n Symptoms and signs of myocardial ischaemia n Also –Changes in heart rate /rhythm –Changes in blood pressure

18. Acute Myocardial Infarction Confirming the diagnosis n Typical chest pain n Electrocardiographic changes –ST elevation –new LBBB (left bundle branch block) n Myocardial enzyme elevation –Creatine kinase (CK-MB) –Troponin

19. Acute Myocardial Infarction Treatment n Rest, sit up and reassure patient n Oxygen n Analgesia (opiate, sublingual nitrate) n Aspirin n Prepare for basic life support

20. Acute Myocardial Infarction Medical treatment n Rest, oxygen, analgesia, aspirin n Thrombolysis n Primary angioplasty n Beta-Blockers n ACE inhibitors

21. Acute Myocardial Infarction Complications n Death ( 18% within 1 hour, 36% within 24 hours) n Non-fatal arrhythmia n Acute left ventricular failure n Cardiogenic shock n Papillary muscle rupture and mitral regurgitation n Myocardial rupture and tamponade n Ventricular aneurysm and thrombus