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Title: Ischemic%20Heart%20Disease%20CVS3


1
Ischemic Heart DiseaseCVS3
  • Hisham Alkhalidi

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Ischemic Heart Disease
  • A group of related syndromes resulting from
    myocardial ischemia

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Ischemic Heart Disease
  • The vast majority of ischemic heart disease is
    due to coronary artery atherosclerosis
  • Less frequent contributions of
  • vasospasm
  • vasculitis
  • Is it exactly the same as coronary artery disease
    (CAD)?
  • Frequently yes

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Ischemic Heart Disease Angina pectoris
  • Chest pain
  • Can radiate down the left arm or to the left jaw
    (referred pain)
  • Due to inadequate perfusion
  • Duration and severity is not sufficient for
    infarction

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Ischemic Heart Disease Stable angina
  • Occurring reliably after certain levels of
    exertion
  • Typically due to atherosclerotic disease with
    75 (critical stenosis) fixed chronic stable
    stenosis

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Ischemic Heart Disease Unstable angina
  • Unstable (occurring with progressively less
    exertion or even at rest)
  • Results from a small fissure or rupture of
    atherosclerotic plaque triggering
  • Platelet aggregation
  • Vasoconstriction
  • Formation of a mural thrombus that may not be
    occlusive
  • Usually proceed MI

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Ischemic Heart Disease Variant angina
  • Vessel spasm or Prinzmetal angina
  • Without fixed atherosclerotic disease
  • The etiology is not clear

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Ischemic Heart Disease Myocardial infarction
  • The severity or duration of ischemia is enough to
    cause cardiac muscle death
  • Typically results from acute thromboses that
    follow plaque disruption

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Ischemic Heart Disease MI types
  • Transmural
  • Full thickness (gt50 of the wall)
  • Subendocardial
  • Inner 1/3 of myocardium
  • Two mechanisms
  • Fixed atherosclerosis but with increased demand,
    vasospasm or hypotension OR
  • Evolving transmural with relieve of the
    obstruction (often multifocal)

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Ischemic Heart Disease MI, common locations
  • In Right dominent coronary artery heart (90 of
    population)
  • 2 cm proximal LAD (up to 50)
  • anterior left ventricle
  • anterior septum
  • apex circumferentially
  • Left circumflex ( up to 20)
  • infarct involves lateral left ventricle except
    the apex.
  • 1st and last thirds of RCA (up to 40)
  • posterior left ventricle
  • posterior septum
  • right ventricular free wall, sometime

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Ischemic Heart Disease
  • Ischemia to myocardium rapidly (minutes) leads to
    loss of function and causes necrosis after 20 to
    40 minutes

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Ischemic Heart Disease Clinical picture of MI
  • Severe, crushing substernal chest pain or
    discomfort that can radiate to the neck, jaw,
    epigastrium, or left arm
  • Diaphoresis
  • Nausea
  • Dyspnea
  • Can be silent (DM, old age)

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Ischemic Heart Disease ECG
  • Changes such as
  • Q waves (indicating transmural infarcts)
  • ST-segment abnormalities
  • T-wave inversion
  • Arrhythmias

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Ischemic Heart Disease Laboratory evaluation
  • Cardiac troponins T and I (TnT, TnI)
  • Creatine kinase (CK, and more specifically the
    myocardial-specific isoform, CK-MB)
  • Lactate dehydrogenase
  • Myoglobin
  • Troponins and CK-MB have high specificity and
    sensitivity for myocardial damage

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Ischemic Heart Disease Laboratory evaluation
  • TnI and TnT are not normally detectable in the
    circulation
  • After acute MI both troponins
  • Become detectable after 2 to 4 hours
  • Peak at 48 hours
  • Their levels remain elevated for 7 to 10 days

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Ischemic Heart Disease Laboratory evaluation
  • CK-MB is the second best marker
  • CK-MB activity
  • Begins to rise within 2 to 4 hours of MI
  • Peaks at 24 to 48 hours
  • Returns to normal within approximately 72 hours

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Ischemic Heart Disease Complications of MI
  • At least 80 will suffer
  • Cardiogenic shock (gt40 infarct of LV)
  • Congestive heart failureCHF
  • Arrhythmia
  • Rupture of ventricle, free wall, septum, or
    papillary muscle
  • Aneurysm formation,
  • Mural thrombus, potentially soursce of emboli
  • Pericarditis

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Ischemic Heart Disease MI death and
complications rates
  • 25 die, presumably due to arrythmia
  • 10 of the rest will die within a month
  • 80-90 will develop complications
  • Overall 30 die in the 1st year and then 10 per
    year

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Chronic ischemic heart disease
  • Progressive heart failure due to ischemic injury,
    either from
  • prior infarction(s) (most common)
  • chronic low-grade ischemia

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Ischemic Heart Disease Sudden cardiac death
  • Unexpected death from cardiac causes either
    without symptoms or within 1 to 24 hours of
    symptom onset (different authors use different
    time points)
  • Results from a fatal arrhythmia, most commonly in
    patients with severe coronary artery disease

41
Ischemic Heart Disease Acute coronary syndrome
  • is applied to three catastrophic manifestations
    of IHD
  • Unstable angina
  • Acute MI
  • Sudden cardiac death

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