Download 08_Main symptoms and syndromes in ischemic heart disease

Main symptoms and syndromes in
ischemic heart disease
•
Prof. S.M.Andreychyn
DEFINITION
IHD - synonims – coronary
disease,
coronary
insufficiency – is severe
chest pain due to ischemia
(a lack of blood and hence
oxygen supply) of the heart
muscle, generally due to
obstruction or spasm of the
coronary arteries (the heart's
blood vessels).
Clinical forms of IHD
• 1. Sudden coronary death or heart arrest
(HA)
• 1.1. HA with following resuscitation.
• 1.2. HA with following mortal outcome.
• 2. Angina pectoris (AP)
• 2.1 Stable angina at exertion.
• 2.1.1 Stable angina at exertion (
functional class should be determined).
• 2.1.2 Stable angina at exertion in
angiographically intact vessels
(coronary syndrome X).
• 2.2. Angiospastic angina (angina in rest,
spontaneous, variant, Prinzmetals’ angina)
• 2.3. Unstable angina.
• 2.3.1. Primary angina.
• 2.3.2. Progressive angina.
• 3. MYOCARDIAL INFARCTION (МI)
• 4. CARDIOSCLEROSIS (postinfarctional,
focal and diffuse)
• 5. MYOCARDIAL ASCHEMIA WITHOUT
PAIN
• 6. CARDIAC RRHYTHM DISORDERS
(form)
• 7. HEART FAILURE (stage, functional class)
RISK FACTORS
 Smoking
 alcohol abuse
 high arterial pressure
 Dislipidemia
 Diabetes mellitus
 Obesity
 Excessive consumption of animal fats
 thrombogenic factors
 Lack of physical activity
Causes of IHD
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85 % - stenotic atherosclerosis
of coronary arteries
10 % - spasm of coronary
arteries
5 % - transitory thrombocytes
aggregates
100 % - combination of these
factors
Morbidity in males is 4 times
higher than in females
Angina pectoris
Angina is attack of
retrosternal
pressing
pain
or
chest
dyscomfort
which
occures in physical load
or emotional strain and
is caused by myocardial
ischemia.
Provoking factors:
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physical load;
Emotional strain;
cold;
overeating;
smoking;
Factors which decrease pain:
• Refuse of physical load;
• Nitroglycerin/
• Patient try to stay or lie down in attack.
Stable angina at exertion
• Occurs in the same provoking factors,
is often follows with the same
complains and changes on ECG.
AP functional classes
• І FC – attacks occur in a whery high load 1 – 2 times a year.
Coronary arteries lumen is narrowed not more than on 50 %.
• ІІ FC – attacks occur in walking on the plane surface on the
diastance more than 500м, in going more than on 1 floor upstairs 2 –
3 times a week. Coronary arteries lumen is narrowed not more than
on 75 %.
• ІІІ FC – attacks occur in walking on the plane surface on the
diastance 200 – 300 м, in going 1 floor upstairs. Postinfarctional
angina. Coronary arteries lumen is narrowed more than on 75%.
• ІV FC – attacks occur in walking on the plane surface on the
diastance less than on 100 м, in rest. Combination of coronary and
myocardial insufficiency. Complete obturation of coronary arteries.
Clinical pattern
• The major sign of stenocardia is attack-like pain in the
area of heart. It has squeezing, cutting or burning
character with localization behind a breastbone,
irradiates in a left arm (left shoulder-blade, left half of
neck, lower jaw, sometimes – in a right shoulder or
shoulder-blade). Duration of pain of 5-10 min (more
frequently – 2-5 min).
Coronary syndrome X
• This is a stable angina at exertion
when small coronary arteries are
affected.
• Clinical pattern is the same as for
stable angina but coronarography
does not show obturation of coronary
arteries.
Angiospastic angina
• Caused by spasm of coronal arteries. Arises up
in young persons, mainly at night, in rest, when
tone of vagus nerve prevails. Duration of attack
till 30 min, during this time ECG shows changes
typical for MI (depression of ST segment)
which disappear after stopping of attack or
application of spasmolysants. Nitrates are
uneffective with the purpose of removal of
attacks.
Unstable angina
Acute coronary syndrome
• This is a result of myocardial ischemia caused
by thrombosis of coronaty artery and its
complete occlusion.
• The syndrome includes:
• 1. Unstable angina pectoris.
• Non-Q myocardial infarction.
• 3. Q- myocardial infarction.
Unstable angina pectoris
• At a stenocardia which arose up first, the attacks
of pain are observed during 28 days for persons,
which did not have clinical signs of stenocardia
before. Usually this is angina at exertion.
• Progressing angina is the state, at which
duration, intensity and frequency of anginal
attacks, grow in a dynamics, and the usual dose
of medications which take off an attack becomes
insufficient, that requires its permanent increase.
• Characteristic for progressing stenocardia is pressing pain
behind the sternum, which periodically calms down and grows,
is not removed by nitrates, is accompanied with swweating,
dyspnea, arrhythmia, fear of death. The episodes of attacks of
anginal pain become more frequent, and periods between
attacks shorten.
• Every next attack is heavier, than previous. Nitrates
(nitroglycerine, Nitrosorbidum), which removed the attacks of
anginal pain before, are uneffective, although a patient uses
considerably increased their amount.
Associated manifestations
• Pain can arise up not obviously due to emotional or
physical loading, but also in rest. Sometimes only
narcotic facilities remove him. On a background a
stenocardia there can be an attack of sharp leftventricular insufficiency with dyspnea, dry cough,
bubbling in the chest.
Diagnostics of angina pectoris
functional tests:
• - exposure to cold;
• - test with hyperwentilation;
tests with dynamic physical load:
• а) veloergometry;
• б) tredmile test;
emotional stress-test;
pharmacological tests;
• а) test with dityridamole;
• б) test with isadrine;
• в) test with ergometrine;
transesophageat atrial electrostimulation;
daily ECG-mpnitoring
coronary angiography.
Tests with physical load
Echocardiography
Classification of IM
• Acute myocardial infarction with the presence of wave Q
(transmural).
• Acute myocardial infarction without Q wave.
• Acute subendocardial myocardial infarction.
• Acute myocardial infarction (undefined).
• Recurrent myocardial infarction.
• Repeated myocardial infarction.
• Acute coronary insufficiency.
Myocardial infarction (MI)
• It is necrosis of area cardiac to the
muscle, that is
predefined by an ischemia that arises
up sharply as a result
of disparity of coronal blood stream
to the requirements of
myocardium in oxygen.
Causes of IHD
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85 % - stenotic atherosclerosis of coronary arteries
10 % - spasm of coronary arteries
5 % - transitory thrombocytes aggregates
100 % - combination of these factors
Morbidity in males is 4 times higher than in females
Provocation factors
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Smoking
Dyslipidemia
Arterial hypertension
Diabetes mellitus
Obesity
Dietary factors
Thrombogenic factors
Lack of physical activity
Alcohol abuse
The accumulation of cholesterol in the
vascular wall - atherosclerotic plaque
• Schematic of MI:
1 - subendocardial
2 - transmural
3 - subepicardial
4 - intramural
2
Myocardial infarction can be:
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Time of occurrence:
-primary;
-second (after 1 month. following the first);
- recurrent (in the range of 72 hours. Before 28 days
after the first).
Clinical variants of MI
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Anginous variant
Abdominal variant
Asthmatic variant
Arrythmic cariant
Cerebral variant
Asymptomatic variant
Clinics – main symptom
• Pain pattern simillar to angina pectoris but pain intensity
is much more severe that is why nitrates can’t release
pain. Pain duration is longer.
If patient feels pain, you must ask him about:
• 1. The nature of pain.
• 2. Localization.
• 3. Duration.
• 4. Irradiation.
• 5. Contact with the physical, emotional stress,
movements, breathing, eating, and other factors.
• 6. Effect of different drugs on pain.
Pain syndrom
Pain syndrom
The second severity of symptoms is
dyspnea. It may be accompanied by
pain or be the only sign of MI.
Next complains can be tachycardia, different
arrhythmias, high temperature, swelling.
Diagnosis of MI:
• Typical history and clinical presentation.
• Characteristic of ECG changes.
• There are three zones on ECG:
• - Zone of ischemia - negative or high T wave;
• - Zone of damage - shift segment S-T;
• - Zone of necrosis – Q wave larger then ¼ R wave
Wave T
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Shows the process of rapid ventricular repolarisation.
Always positive in I - II, aVF, V2 - V6.
In the third, aVL, V1 can be positive or negative.
Duration 0.12 - 0.16 s, amplitude 2.5 - 6mm.
Wave Q
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It is excitation interventricular septum.
Duration to 0.03 sec., height does not exceed ¼ wave R.
Sometimes can not register.
Registration Q wave even small amplitude in leads V1 V3 pathology.
Stages of MI
І. Superacute (before the development of necrosis) –
clinical pattern of prolonged attack of anginous pain
(duration 30 min – 2 hours).
Acute stage
• ІІ. Acute stage (development of myocardial necrosis) – 2
– 7 days
• - pain disappears;
• - manifestation of heart failure
Subacute period
• ІII. Subacute period (initial organization of a scar,
displacement of nectoric tissues with connective one) – 3
weeks.
Postinfarctional stage
• IV. Postinfarctional stage (final
organization of a scar), lasts for 3-6
month).
ST segment elevation
QS wave
Display units infarction on ECG
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I - the front wall of the left ventricle
II - intermediate (repeats I or III toward pathology)
III - postlateral diaphragmatic or right ventricle
aVR - basal parts of the left ventricle
aVL - upper lateral departments of left ventricle
aVF - diaphragmatic departments or right ventricle
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V1 - front wall
V2 - front wall
V3 – partition (septum)
V4 - top
V5 – lower lateral departments of the left
ventricle
• V6 – lower lateral departments of the left
ventricle
ECG signs of acute myocardial infarction
with Q wave
• Anterior MI - presence of Q or QS waves in V1 - V4.
• Lower (posterior diaphragmatic) - the presence of Q or QS
waves in II, III and aVF leads.
• Side - the presence of Q or QS waves in and aVL, V5 - V6.
• Posterior - reciprocal ECG changes in V1 - V2 leads.
Blood tests
• Serum troponin I or T levels (or CK-MB if troponin is not
available).
• Full blood count.
• Serum creatinine and electrolyte levels, particularly
potassium concentration, as hypokalaemia is associated with
an increased risk of arrhythmias, especially ventricular
fibrillation (grade B recommendation).
• Serum creatinekinase (CK) level.
• ALT, AST, LDG levels
• Leucocitosis
• Serum lipid levels (fasting levels of total cholesterol, lowdensity-lipoprotein cholesterol, high-density-lipoprotein
cholesterol and triglycerides) within 24 hours.
• Blood glucose level.
Scheme of coronarography
Treatment of MI
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A - Aspirin and Antianginal therapy
B - Beta-blocker and Blood pressure
C - Cigarette smoking and Cholesterol
D - Diet and Diabetes
E - Education and Exercise