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Ischemic Heart Disease(IHD – coronary Heart Disease)

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

objectives:

At the end of this session the trainee will be able to • be able to discuss the burden of IHD.• describe essential elements in history taking & examination• develop a differential diagnosis of chest pain.• describe appropriate diagnostic testing for chest pain.• discuss modifiable & non modifiable risk factors for cardiac disease.• describe the use of investigation in the evaluation of a patient with

chest pain.• appropriatly use of specialty referral.

Prevalence of IHD

• Heart diseases responsible for overal deaths in the

Saudi population:

– IHD : 17%

– Hypertensive heart disease 9%

– CVA : 4%

18th scientific session of the Saudi Heart Association. 2007 http://www.highbeam.com/doc/1G1-158905180.html 

History taking in CAD

• Patient characteristics (Name, age, sex,occupation)

• Pain (duration, location, intensity,nature,aggravating factors

• Associated symptoms (Dyspnea, syncope….etc)

• Past history (HPN,DM,COPD..ETC)

• Family history (coronary artery disease ,pneumothorax)

• Drug history (antiangina,anti diabetic..etc)

• Life style (Diet, exercise, alcohol, smoking )

• Psychosocial (ICE, anxiety, stress )

What characteristics of the chest pain might make you more concerned for cardiac chest pain?

• Location• Associated

Symptoms• Quality• Chronology• Onset

• Duration• Intensity• Exacerbating• Relieving• Situation

Physical Examination

• General Examination – patient status: stable,notstable,inpain or not in pain.

– Vital signs.

– Obese or overweight.

– Skin appearance.

• Cardiovascular &respiratory system examination– BP, Pulse rate, JVP.

– Chest :apex beat deviation, crepitations, decrease breath sounds.

– Heart : 1st & 2nd heart sounds, gallop, friction rub.

– Abdomen: tenderness, guadring….

Any exam findings that might help distinguish cardiac from non cardiac chest pain?

• General Appearance – may suggest seriousness of

symptoms.

• Vital signs – marked difference in blood

pressure between arms suggests aortic dissection

• Palpate the chest wall – Hyperesthesia may be due

to herpes zoster

• Complete cardiac examination– pericardial rub– Ischemia may result in MI

murmur, S4 or S3

• Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation

What would be the differential diagnosis for

chest pain?

Life threatening Causes Non-life threatening CausesCardiovascular(16%):• Myocardial infarct.• Angina.•Thoracic aortic dissection.

Pulmonary (5%):•Pulmonary embolus.•Pulmonary infarction.•Tension pneumothorax.•Pneumonia.•Pleurisy.

Chest wall (33%):•Trauma•Fracture•Costo-chondritis.•Musculoskeletal.

•Gastrointistinal(20%):•Esophageal spasm•Esophagitis.•Gall bladder disease.•Peptic ulcer disease.•pancreatitis

Psychatric (9%):• Anxiety.

Spinal dysfunction:• Cervical disease.

Infections (rare):• Herpes Zoster.

..

The risk factors for CAD

• Age > 45 (male) and >55 (female).• Smoking.• Family history.• Hyperlipidemia. • Diabetes. • Hypertension.• Obesity.• Sedentary life style.• Anxiety.• Drug addiction.• Past History.

Any tests that might help in diagnosis?

•History and Examination

•ECG

•Cardiac Enzymes

•Chest x-ray.

•Upper GI endoscopy.

Cont…

• ECGST elevation of > 1mm or new Q in 2 leads

– Sensitivity 45%

Above + ST depression or T-wave inversion – Sensitivity 79%– False positive rate = 17%

20% of patients having an MI will have a normal ECG initally

Cont…Cardiac enzymes:• Troponin, CK, myoglobin

– 88-90% sensitive at 4-6 hours– 95-100% sensitive 8-12 hours

Source: Am Heart J 1998 Aug;136(2):237-44

Risk CategoryRisk CategoryLDL GoalLDL Goal(mg/dL)(mg/dL)

LDL Level at LDL Level at Which to Initiate Which to Initiate

Therapeutic Therapeutic Lifestyle Changes Lifestyle Changes

(TLC) (mg/dL)(TLC) (mg/dL)

LDL Level at Which LDL Level at Which to Considerto Consider

Drug Therapy Drug Therapy (mg/dL)(mg/dL)

CHD or CHD Risk CHD or CHD Risk EquivalentsEquivalents

(10-year risk >20%)(10-year risk >20%)

Very high riskVery high risk

<<100100

< < 7070) ) VHRPVHRP((

100100 130 130 (100(100––129: drug 129: drug

optional)optional)

<) <) 100100 : :drug optionaldrug optional((

22 + +Risk Factors Risk Factors (10-year risk (10-year risk 20%)20%)

))moderately high moderately high risk ptrisk pt( (

1010--year risk < 10%year risk < 10%

<<130130

<<100100))theraputic theraputic optionoption((

<<130130

100100

130130

1010--year risk 10year risk 10––20%: 20%: 130130

100-129100-129

1010--year risk <10%: year risk <10%: 160160

00––11 Risk FactorRisk Factor <<160160 160160

190 190 (160(160––189: LDL-189: LDL-lowering drug lowering drug

optional)optional)

• Diabetes is regarded as a CHD Risk Equivalent

• 10-year risk for CHD 20%

• High mortality with established CHD

– High mortality with acute MI

– High mortality post acute MI

Initial Approach• ABC assessment

• 100% Oxygen

• Aspirine

• Nitroglycerine

• IV access

• Morphine

• Monitoring

• ECG quickly

Action Plan

Action Plan

Source: http://www.aafp.org/afp/20050701/119.html

Referral

Refer urgently all the serious conditions with chest pain:

• Cardiac causes.• Esophageal spasm.• Pulmonary embolism.• Any other cases not responding to usual treatment.

Important Points• The likelihood of acute coronary syndrome (low, intermediate,

high) should be determined in all patients who present with chest pain.

• A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain.

• Cardiac markers (troponin T, troponin I, and/or creatine kinase-MB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome.

http://www.aafp.org/afp/20050701/119.html

Important Points

• A normal electrocardiogram does not rule out acute coronary syndrome.

• When used by trained physicians, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (a computerized, decision-making program built into the electrocardiogram machine) results in a significant reduction in hospital admissions of patients who do not have acute coronary syndrome.

http://www.aafp.org/afp/20050701/119.html