APPROACH TO A PATIENT WITH IHD Mukesh Shanker S.no. 22

THE CAUSES : Atherosclerosis Vaso Spasm Aortitis Severe LV Hypertrophy Aortic Stenosis Severe Anemia Micro vascular Angina

Supply Demand THE PATHOPHYSIOLOGY : INCREASED DEMAND Heart Rate, BP, Myocardial Contractility, LV Hypertrophy, AS etc. DECREASED SUPPLY Duration of Systole, CAPP, Tone, HB, O₂ etc.

THE RISK 1 + 1 ≠ 2

CHD HEART FAILURE & ARRYTHMIAS Myocardial dysfunction/ Altered conduction due to infarction or ischemia SUDDEN DEATH Ventricular arrhythmia, asystole Massive myocardial infarction

Stable Angina Unstable Angina / Subendocardial MI Transmural MI / Sudden Death Pathologic Basis Of Disease.

STABLE ANGINA:

NYHA FUNCTIONAL CLASSIFICATION: Patients have cardiac disease But without resulting limitation of physical activity Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or Anginal pain. Patients have cardiac disease Slight limitation of physical activity Ordinary physical activity results in fatigue, palpitation, dyspnea or Anginal pain. Patients have cardiac disease Marked limitation of physical activity Less than Ordinary physical activity causes fatigue, palpitation, dyspnea or Anginal pain. Comfortable at Rest. Patients have cardiac disease Inability to carry out any physical activity without discomfort. Any physical activity causes fatigue, palpitation, dyspnea or Anginal pain. Symptoms at Rest.

TREADMILL TEST : Monitor Symptoms, ECG, BP. Stop : chest pain, breathless; ST depression >2mV ; SBP >10mmHg ; Ventricular Tachyarrthmias. Flat /Down sloping is significant. MYOCARDIAL PERFUSION SCANNING : Stress Myocardial Radio nucleotide perfusion imaging. Using technetium 99m or thallium. Exercise or pharmacological. 2D ECHO Or CARDIAC MR Or CT. CORONARY ARTERIOGRAPHY : Outlines the lumina. If patient symptomatic despite therapy. Before PCI / CABG.

ACUTE CORONARY SYNDROME:

UA : Angina pectoris or equivalent ischemic discomfort with At rest/ minimal exertion ; >10min. Or Severe and new onset Or Crescendo pattern. Angina pectoris or equivalent ischemic discomfort with At rest/ minimal exertion ; >10min. Or Severe and new onset Or Crescendo pattern. AND Elevated Cardiac Biomarkers. ST segment depression/T wave inversion. NSTEMI : STEMI : Myocardial Infarction : Myocardial Ischemia Myocardial Necrosis Elevated Cardiac Biomarkers. ST Segment Elevation.

ELECTROCARDIOGRAPHY: Lateral Wall Inferior Wall Anterior Wall

NSTEMI : ST segment Depression. Transient elevation. T wave inversion. R wave decreases. No Q wave

STEMI : ST segment Elevation. R wave decreases. Q wave Appear. T wave inversion. ST segment normalize.

CARDIAC BIOMARKERS: Proteins Released from necrotic heart muscles. Seen in : NSTEMI STEMI. Preferred Biochemical Marker Is cTnT & cTnI

OTHER INVESTIGATIONS: BLOOD TESTS: Leukocytosis ESR increased CRP increased CHEST X - Ray: Pulmonary Edema Cardiomegaly ECHOCARDIOGRAPHY: Wall Motion Abnormality Septal Defect MR Pericardial Effusion

THE CRITICAL PATHWAY FOR ED EVALUATION OF CHEST PAIN. Assess Likelihood Of CHD : History & Examination High/Intermediate likelihood. Low likelihood Stable Angina Atypical/ other cause. Investigation : ECG Cardiac Biomarkers Imaging. Treadmill Test Imaging ECG to rule out X Ray Others Assessment : Repeat Assess Risk Find a Cause Classify : UA NSTEMI STEMI Critical Not Critical Manage : Discharge Follow Up Treat Admit in CU & Treat +ve +ve +ve +ve

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