ischaemic heart disease

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ischaemic heart disease ischaemic heart disease pharmacological management of ischaemic heart disease and acute myocardial infarction introduction coronary heart disease (chd) is the most common form of heart disease an estimated 330 000 people have a myocardial infarct each year approximately 1.3 million people have angina each year introduction disease of the coronary arteries is almost always due to atheroma and its complications particularly thrombosis myocardial ischemia results when there is an imbalance between myocardial oxygen supply and demand most occurs because of atherosclerotic plaque with in one or more coronary arteries limits normal rise in coronary blood flow in response to increase in myocardial oxygen demand oxygen carrying capacity the oxygen carrying capacity relates to the content of hemoglobin and systemic oxygenation when atherosclerotic disease is present, the artery lumen is narrowed and vasoconstriction is impaired coronary blood flow cannot increase in the face of increased demands and ischemia …

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normal normal elevated elevated ecg often normal often st depression st segment elevation no st segment elevation angina when ischemia results it is frequently accompanied by chest discomfort: angina pectoris in the majority of patients with angina, development of myocardial ischemia results from a combination of fixed and vasospastic stenosis chronic stable angina may develop sudden increase in frequency and duration of ischemic episodes occurring at lower workloads than previously or even at rest known as unstable angina: up to 70% patients sustain mi over the ensuing 3 months angina: cont patients with mild obstruction coronary lesions can also experience unstable angina >90% of acute mi result from an acute thrombus obstructing a coronary artery with resultant prolonged ischemia and tissue necrosis treatment of angina treatment of chronic angina is directed at minimizing myocardial oxygen demand and increasing coronary flow where as in the acute syndromes of unstable angina or …

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ion if higher risk may manage with more invasive rx determine if fibrinolysis candidate meets criteria with no contraindications determine if pci candidate based on availability and time to balloon rx fibrinolysis indications st segment elevation >1mm in two contiguous leads new lbbb symptoms consistent with ischemia symptom onset less than 12 hrs prior to presentation absolute contraindications for fibrinolysis therapy in patients with acute stemi any prior ich known structural cerebral vascular lesion (e.g., avm) known malignant intracranial neoplasm (primary or metastatic) ischemic stroke within 3 months except acute ischemic stroke within 3 hours suspected aortic dissection active bleeding or bleeding diathesis (excluding menses) significant closed-head or facial trauma within 3 months stemi cardiac care step 2: determine preferred reperfusion strategy fibrinolysis preferred if: 90min door to balloon minus door to needle > 1hr door to needle goal 3 hr high risk stemi killup 3 or higher stemi dx …

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days at 23% long term mortality reduction in stemi approximate 13% reduction in risk of progression to mi in patients with threatening or evolving mi symptoms be aware of contraindications (chf, heart block, hypotension) reassess for therapy as contraindications resolve ace-inhibitors / arb (class i, level a) start in patients with anterior mi, pulmonary congestion, lvef 5.0 lvef 50 years probable ischemic symptoms recent cocaine use physical examination new transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales extracardiac vascular disease chest discomfort reproduced by palpation ecg new or presumably new transient st-segment deviation (> 0.05 mv) or t-wave inversion (> 0.2 mv) with symptoms fixed q waves abnormal st segments or t waves not documented to be new t-wave flattening or inversion of t waves in leads with dominant r waves normal ecg serum cardiac markers elevated cardiac troponin t or i, or elevated ck-mb normal normal risk stratification …

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rinciples of treatment increase oxygen supply or reduce oxygen demands of myocardium reduce heart rate reduce preload reduce afterload improve coronary blood flow symptomatic treatment nitrates beta blockers calcium channel blockers potassium channel activators selective pacemaker if current inhibitorivabradine (procolalan) describing any drug moa and pharmacological properties indications cautions/contraindications side effects important interactions dose/overdose nitrates - mode of action metabolised to release nitric oxide (no)  cgmp dephosphorylation of myosin light chains increased intracellular calcium muscle relaxation nitrates - mode of action venodilation -  preload coronary artery vasodilation -  supply moderate arteriolar dilation -  afterload pharmacological properties glyceryl trinitrate (gtn) short acting, first pass metabolism sublingual/intravenous/patch administration isosorbide dinitrate intermediate acting sublingual/intravenous/oral administration isosorbide mononitrate long acting oral administration pharmacological properties tolerance (tachyphylaxis) - reduced therapeutic effects “monday morning sickness” ? due to depletion of free tissue –sh long-acting preparations /infusions/transdermal patches “nitrate free period” indications relief …

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ischaemic heart disease ischaemic heart disease pharmacological management of ischaemic heart disease and acute myocardial infarction introduction coronary heart disease (chd) is the most common form of heart disease an estimated 330 000 people have a myocardial infarct each year approximately 1.3 million people have angina each year introduction disease of the coronary arteries is almost always due to atheroma and its complications particularly thrombosis myocardial ischemia results when there is an imbalance between myocardial oxygen supply and demand most occurs because of atherosclerotic plaque with in one or more coronary arteries limits normal rise in coronary blood flow in response to increase in myocardial oxygen demand oxygen carrying capacity the oxygen carrying capacity relates ...

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