Ischemic heart disease (IHD)Ischemic heart disease (IHD). . Classification. Angina pectorisClassification. Angina pectoris. . Classification. Emergency careClassification. Emergency care. . Cardiopulmonary resuscitationCardiopulmonary resuscitation..

DefinitionDefinition

IHDIHD - synonims- synonims – – coronary diseasecoronary disease, , coronary insufficiencycoronary insufficiency – – is severeis severe chest painchest pain due to due to ischemia ischemia (a lack (a lack of blood and henceof blood and hence oxygen oxygen supply) supply) of theof the heart muscle heart muscle, generally due , generally due to obstruction or spasm of theto obstruction or spasm of the coronary arteriescoronary arteries (the heart's blood (the heart's blood vessels). vessels).

EthiologyEthiology.. • SmokingSmoking• DyslipidemiaDyslipidemia• Arterial hypertensionArterial hypertension• Diabetes mellitusDiabetes mellitus• ObesityObesity• Dietary factorsDietary factors• Thrombogenic factorsThrombogenic factors• Lack of physical activityLack of physical activity• Alcohol abuseAlcohol abuse

Causes of IHDCauses of IHD

• 85 % - 85 % - stenotic atherosclerosis of stenotic atherosclerosis of coronary arteriescoronary arteries

• 10 % 10 % - spasm of coronary arteries- spasm of coronary arteries• 5 % 5 % - transitory thrombocytes - transitory thrombocytes

aggregatesaggregates• 100 % 100 % - combination of these factors- combination of these factors• Morbidity in males is 4 times higher Morbidity in males is 4 times higher

than in femalesthan in females

PathogenesisPathogenesis

Clinical forms of IHDClinical forms of IHD • 1. 1. Sudden coronary death or heart arrest Sudden coronary death or heart arrest

(HA)(HA)– 11.1. .1. HA with following HA with following resuscitationresuscitation..– 1.2. 1.2. HA with following mortal outcomeHA with following mortal outcome. .

• 2. 2. Angina pectoris (AP)Angina pectoris (AP)• 2.1 2.1 Stable angina at exertion.Stable angina at exertion.• 2.1.1 2.1.1 Stable angina at exertionStable angina at exertion ( functional ( functional

class should be determined)class should be determined)..• 2.1.2 2.1.2 Stable angina at exertionStable angina at exertion in in

angiographically intact vesselsangiographically intact vessels ( (coronary coronary syndrome X)syndrome X)..

• 2.2. 2.2. Angiospastic anginaAngiospastic angina ( (angina in restangina in rest, , spontaneousspontaneous, , variantvariant, , Prinzmetals’ anginaPrinzmetals’ angina))

• 2.3. 2.3. Unstable anginaUnstable angina..• 2.3.1. 2.3.1. Primary anginaPrimary angina..• 2.3.2. 2.3.2. Progressive anginaProgressive angina..• 3. 3. MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION (М (МII))• 4. 4. CARDIOSCLEROSIS CARDIOSCLEROSIS ((postinfarctionalpostinfarctional, ,

focal and diffusefocal and diffuse))• 5. 5. MYOCARDIAL ASCHEMIA WITHOUT PAINMYOCARDIAL ASCHEMIA WITHOUT PAIN• 6. 6. CARDIAC RRHYTHM DISORDERSCARDIAC RRHYTHM DISORDERS ( (formform))• 7. 7. HEART FAILUREHEART FAILURE ( (stagestage, , functional classfunctional class))

Angina pectorisAngina pectoris

Angina is attack of retrosternal Angina is attack of retrosternal pressing pain or chest pressing pain or chest dyscomfortdyscomfort which occures in which occures in physical load or emotional physical load or emotional strain and is caused by strain and is caused by myocardial ischemia.myocardial ischemia.

Provoking factorsProvoking factors::• physical loadphysical load;;• Emotional strainEmotional strain;;• coldcold;;• overeatingovereating;;• smokingsmoking;;Factors which decrease painFactors which decrease pain::• Refuse of physical loadRefuse of physical load;;• Nitroglycerin/Nitroglycerin/• Patient try to stay or lie down in attackPatient try to stay or lie down in attack..

Stable angina at exertionStable angina at exertion

•Occurs in the same provoking Occurs in the same provoking factorsfactors, , is often follows with is often follows with the same complains and the same complains and changes on ECG.changes on ECG.

AP functional classesAP functional classes• І І FCFC – – attacks occur in a whery high load attacks occur in a whery high load 1 1

– 2 – 2 times a yeartimes a year. . Coronary arteries lumen Coronary arteries lumen is narrowed not more than on is narrowed not more than on 50 %.50 %.

• ІІ ІІ FCFC – – attacks occur in walking on the attacks occur in walking on the plane surface on the diastance more than plane surface on the diastance more than 500м, 500м, in going more than on 1 floorin going more than on 1 floor upstairs upstairs 2 – 3 2 – 3 times a weektimes a week. . Coronary Coronary arteries lumen is narrowed not more than arteries lumen is narrowed not more than on 75on 75 %. %.

• ІІІ ІІІ FCFC – – attacks occur in walking on the attacks occur in walking on the plane surface on the diastance plane surface on the diastance 200 – 300 200 – 300 м, м, in going 1 floorin going 1 floor upstairsupstairs.. Postinfarctional anginaPostinfarctional angina. . Coronary Coronary arteries lumen is narrowed more than on arteries lumen is narrowed more than on 7575%.%.

• ІІVV FCFC – – attacks occur in walking on the attacks occur in walking on the plane surface on the diastance less than plane surface on the diastance less than on on 100 м, 100 м, in restin rest. . Combination of Combination of coronary and myocardial insufficiencycoronary and myocardial insufficiency. . Complete obturation of coronary Complete obturation of coronary arteriesarteries..

Clinical patternClinical pattern • The major sign of stenocardia is attack-The major sign of stenocardia is attack-

like pain in the area of heart. It has like pain in the area of heart. It has squeezing, cutting or burning character squeezing, cutting or burning character with localization behind a breastbone, with localization behind a breastbone, irradiates in a left arm (left shoulder-irradiates in a left arm (left shoulder-blade, left half of neck, lower jaw, blade, left half of neck, lower jaw, sometimes – in a right shoulder or sometimes – in a right shoulder or shoulder-blade). Duration of pain of 5-shoulder-blade). Duration of pain of 5-10 min (more frequently – 2-5 min).10 min (more frequently – 2-5 min).

Coronary syndrome XCoronary syndrome X• This is a stable angina at exertion This is a stable angina at exertion

when small coronary arteries are when small coronary arteries are affected.affected.

• Clinical pattern is the same as for Clinical pattern is the same as for stable angina but coronarography stable angina but coronarography does not show obturation of coronary does not show obturation of coronary arteries.arteries.

Angiospastic anginaAngiospastic angina• Caused by spasm of coronal arteries. Arises Caused by spasm of coronal arteries. Arises

up in young persons, mainly at night, in up in young persons, mainly at night, in rest, when tone of vagus nerve prevails. rest, when tone of vagus nerve prevails. Duration of attack till 30 min, during this Duration of attack till 30 min, during this time ECG shows changes typical for MI time ECG shows changes typical for MI (depression of ST segment) which disappear (depression of ST segment) which disappear after stopping of attack or application of after stopping of attack or application of spasmolysants. Nitrates are uneffective with spasmolysants. Nitrates are uneffective with the purpose of removal of attacks.the purpose of removal of attacks.

Acute coronary syndromeAcute coronary syndrome• This is a result of myocardial ischemia This is a result of myocardial ischemia

caused by thrombosis of coronaty caused by thrombosis of coronaty artery and its complete occlusionartery and its complete occlusion..

• The syndrome includesThe syndrome includes::• 1. 1. Unstable angina pectoris.Unstable angina pectoris.• Non-Q myocardial infarctionNon-Q myocardial infarction..• 3. 3. QQ- - myocardial infarctionmyocardial 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.

•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 left-ventricular insufficiency with dyspnea, dry cough, bubbling in the chest.

Diagnostics of angina Diagnostics of angina pectorispectoris functional testsfunctional tests::• - - exposure to coldexposure to cold;;• - - test with hyperwentilationtest with hyperwentilation;; tests with dynamic physical loadtests with dynamic physical load::• а) а) veloergometryveloergometry;;• б) б) tredmile testtredmile test;; emotional stress-testemotional stress-test;; pharmacological testspharmacological tests;;• а) а) test with dityridamoletest with dityridamole;;• б) б) test with isadrinetest with isadrine;;• в) в) test with ergometrinetest with ergometrine;; transesophageat atrial electrostimulationtransesophageat atrial electrostimulation;; daily ECG-mpnitoringdaily ECG-mpnitoring coronary angiographycoronary angiography..

Tests with physical loadTests with physical load

Laboratory examinationsLaboratory examinations• Complete blood countComplete blood count – 1 – 1 time a yeartime a year• Byochemical blood serum studyByochemical blood serum study ( (lipid lipid

spectrespectre, , cholesterolcholesterol - 1 - 1 time a year)time a year)• ЕЕCG and functional testsCG and functional tests – 2-3 – 2-3 times times

a year in stable angina depending on a year in stable angina depending on functional classfunctional class. .

TreatmentTreatment• Healthy life stile. Correction of risk factors, Healthy life stile. Correction of risk factors,

limitation of carbonhydratess and limitation of carbonhydratess and saturated fats in diet. Employment. saturated fats in diet. Employment. Psychprrophylaxis.Psychprrophylaxis.

• Medication (nitrates, other antianginal Medication (nitrates, other antianginal preparations on a sedate agents) preparations on a sedate agents) depending on a functional class and depending on a functional class and concomitant diseases. Sanatorium-resort concomitant diseases. Sanatorium-resort treatment. treatment.

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