Download ISCHEMIC HEART DISEASE

ISCHEMIC HEART DISEASE
Afsar fathima
M.Pharm
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.
• 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
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 mid30s
Reasons & risk factors
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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
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.
• 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
Coronary Artery
Pathophysiology
Pathophysiology
Pathophysiology of MI
Pathophysiology of MI
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
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
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.
NORMAL ECG
ST segment depression & T Wave Inversion In Myocardial Ischaemia
NORMAL ECG
ST segment elevation
& T Wave Inversion In Myocardial Infraction
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
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Statins(plaque stabilization)
Drugs used in myocardial infarction
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Oxygen
Morphine. i.v.
Aspirin low dose
Nitroglycerin.SL,
Streptokinase. i.v.
furosemide.i.v.
Propranolol. PO
ACEI
• Heparin/or warfarin
• Clopidogrel
Consequences of Hypertension:
Left Ventricular Hypertrophy
Heart
Hypertensive cardiomyopathy,
IHD, MI.
Cerebral Infarction (Stroke)
Brain:
Hemorrhages
infarction
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
Aspirn + Clopidogrel
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.
Interactions with nitrates
• +sildenafil: contraindicated
• +alcohol: sustained fall of BP
• +propranolol:
reflex tachycardia suppressed
attenuation of beta blocker
induced ventricular dilatation
therapeutic synergy
Beta blockers in angina-rationale
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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