ischemia

Today's lecture is about Ischemia ( to continue what we started last lecture)

Review :

When we talk about ischemic heart disease there are three main cases (issues ) that we need to know in order to differentiate between them :

(1) Stable angina ( chronic artery diseases)

-Acute coronary syndrome: 2-Unstable angina 3-Myocardial infarction

So what is the difference between each case?

Lets remember the stable angina.. Its diagnosed by pain being felt mainly in the chest (thorax) happens when a coronary artery is closed partially by: Atherosclerosis ,thrombosis or embolism ( we explained them in a previous lecture). It happens mainly after doing an exercise or an effort which leads to imbalance between the high demand and supply (remember ischemic HD equation). *Hint : that stable angina's pain is relieved by vasodilators. -How diabetes mellitus is involved in ischemic heart disease? You know that a major cause of ischemia and a destruction cause of t he endothelium i s so aggression in the blood vessels, at first its an endocrine problem t hat have neuropathy microangiopathy characteristics so it will

*cause:

vasoconstriction a decrease in the elasticity (i. e.: cant get back to its normal shape) pain process of healing which is a low cause perfusion And you will have the rest of the story sometime later.

(2) Unstable angina:

Now what's unstable angina? How it differs from stable angina? Angina pectoris that is rapidly worsening (which means that there's an increase in the intensity and the force of pain even the patient were given vasodilators).

*Characteristics:

Sever and of new onset Crescendo pattern. (i.e.: increases in the intensity and the contractility power = force of pain will be increased)

Not relieved by vasodilators i.e.: The coronary artery almost closed (perfusion is less than stable angina)

*Causes:
-Shares common pathophysiological mechanisms with acute MI (Same risk f act ors as stable angina and MI) -Plaque rapture or erosion. -Dynamic obstruction (coronary spasm). -Rapidly advancing coronary atherosclerosis (the most common cause). -History( sometimes without history)

(unpredictable)):
First of all you need to know the progress: if it treated it will become stable angina otherwise it will develop to MI myocardial infarction. History of chronic stable angina may present as new phenomena, Severe Chest pain (Substernal region, radiating to the neck and heart, left shoulder and left arm). *some cases (mainly in old people) have an abdominal pain caused by myocardial infarction.

*Summary of the differences between stable and unstable:

Stable After strenuous exercise Relieved by vasodilators and relaxation. less closed (more perfusion) Fixed stenosis Demand-led ischemia Predictable. *Management:
At home:

Unstable Usually at rest Not relieved More closed(less perfusion) Dynamic stenosis. Supply-led ischemia Unpredictable.

Urgent admission to hospital. -Bed rest( the most important thing ; specially when you are with the patient at home , why? To prevent increasing the demand of heart) -Anti-platelet ( e. g: aspirin, because it prevents the aggregation of platelets)

(note from the doctor):

aspirin is a safe drug(4-5 tablets is acceptable) (therapeutic index is wide): which means that a high dose could be handled by the patient's body. Theres difference between toxic and therapeutic. therapeutic index is narrow this means that the drug is not safe (toxic) so the difference is small. )

Management (in the hospital):

--blockers (e.g: atenolol)...(i.e.: it works on 2, the job of 2 is to increase the contractility so it blocks this increase to decrease the heart demand)

*Remember receptors action :

Alpha 1 :blood vessel vasoconstriction Beta 1 : increase heart rate & contractility Alpha 2 : heart vasodilatation Beta 2 : bronchi dilatation

-IV intra venous or buccal nitrates. -Revascularization. -Bed rest or semi sitting position. -Suction of the secretion if there is in the mouth. -ECG-->blood test-->IV line -->put any solution. (All of these things should be done in one minute.) -Give an analgesic (because the pain is very severe). *The doctor said that its very important to differentiate between the unstable angina and myocardial infarction, how? -First ECG -Then a biochemical test: cardiac enzymes ( cardiac markers): -Troponine(CK) is the most important one, they appear in blood within hours( by taking a blood sample before giving the patient any solution) Located in the blood after an hour and the result can be detected: (+) myocardial infarction or (-) unstable angina. *In other words: the result of troponine(CK) will be positive for myocardial infarction, and negative for unstable angina.

*Myocardial infarction
Occurs when there is zero flow or a very small flow that it cant sustain cardiac muscle function = fatal. Occlusive thrombus in a coronary artery. Clinical features: -Pain (severs, last longer). -Breathlessness. -Vomiting. -Collapse. -Syncope (i.e.: Partial or complete loss of consciousness with interruption of awareness of oneself and ones surroundings).

what indicates the quantity of the dead myocytes and the size of necrosis? The coronary artery which is blocked :

Major a.
high number of dead myocytes big size necrosis theres no perfusion for many regions in t he myocardium

Minor a.
less number of dead myocyte small size necrosis there no perfusion just in one region in the myocardium

*Complications of infarction:
-Arrhythmia (ex: ventricular fibrillation = fatal). -Ischemia (in other places). -Acute circulatory (heart) failure.(i.e.: when theres a massive myocardial infarction). -Pericarditis. -Embolism.

*Causes of death in MI:

-Decreased CO. -Damming of blood in the pulmonary or systemic veins. -Fibrillation. Rupture of the heart

*Surgical treatment of coronary disease.

Aortic-coronary bypass surgery. To make a connection between a healthy artery ( except pulmonary artery )or pulmonary vein to the blocked coronary artery in the blocked area so give him oxygenated blood. Coronary angioplasty. To open a narrowed artery ( closed by aggression) using stent that entered to the artery by Catheter to allow normal flow of the blood.

Myocardial infarction isnt always with pain theres case called silent myocardial infarction not accompanied with pain (silent minimal effect = the area supplied not major) can also cause death (silent massive effect). Last note from the doctor: If theres an old person complaining from abdominal pain Do an ECG cause it may be a heart problem(hard managed),if its an gastric problem it would be a lot easier (easy to be managed),so take care.

Whats the biochemical marker?

Its an enzyme (ckmp, troponin , LDH) appears in the blood after specific time, its function to discover if theres cardiac damage (ex: ischemia) and supported by ECG.

*What is the treatment for the myocardial infarction at home ?

There is No treatment at home but you should do some procedures: -Bed rest. -Reassurance. (i.e.: dont panic the patient). -Aspirin (4-5 tabs). -Take the patient to the hospital.

Done by: Shine group Tareq Hamada Edited by: Challenge Working Team