Ischaemic Heart Disease and Heart Failure Symposium

Presentation of MI

• chest pain

• clamminess/sweating (diaphoresis)

• shortness of breath

• nausea/emesis

• indigestion

• light headedness

• anxiety

ischaemic heart disease

• occurs when there is an imbalance between supply of oxygen and demand of myocardium as

  • blood supply is impaired and/or

  • myocardium has a greater demand

• main cause→ atherosclerosis

causes of inadequate blood supply

• coronary artery lumen narrowing

• coronary artery obstruction

• vasoconstriction

• hypovolemia

• anaemia

prevention of MI

• smoking cessation

• weight loss

• BP control

• exercise

• risk calculation

familial hypercholesterolaemia

• mutation in genes involved in cholesterol metabolism e.g. LDL receptor gene or ApoB

• to be considered in younger patients or those with strong family history

  • early xanthomas

• early primary treatment with statins is effective

pathogenesis of IHD

• coronary artery occlusion

• acute and/ chronic ischaemia

• myocyte dysfunction/death from ischaemia

• recovery possible if rapid reperfusion

• subendocardial myocardium more vulnerable to ischaemia

IHD syndromes

• angina pectoris (stable angina)

• acute coronary syndrome (infarction rather than ischaemia)

  • unstable angina

  • NSTEMI

  • STEMI

ischaemia→ infarction

• can have infarction with incomplete obstruction (NSTEMI)

• atheromatous plaque can rupture- acute thrombus formation/haemorrhage and acute occlusion of the artery

• regional transmural myocardial infarction (STEMI)

occlusion levels of acute coronary syndrome

• STEMI→ total occlusion

• NSTEMI→ incomplete occlusion

• unstable angina→ incomplete occlusion

ECG observations for ACS

• STEMI→ ST elevation

• NSTEMI→ other ischaemic changes/none

• unstable angina→ other ischaemic changes/none

troponin levels in ACS

• STEMI→ raised

• NSTEMI→ raised

• Unstable angina→ normal

cardiac enzymes and markers

• troponins T and I

  • detectable 2-3hrs, peaks at 12-48 hrs, detectable to 7 days

• creatine kinase MB

  • detectable 2-3hrs, peaks at 10-24 hrs, detectable to 3 days

• myoglobin, lactate dehydrogenase isoenzyme 1

management of ACS

• reperfusion→ PCI, thrombolysis rarely used

• acute medical management

• secondary prevention

complications of MI - DARTH VADER

• Death

• Arrhythmia

• Rupture

• Tamponade

• Heart failure

• Valve disease

• Aneurysm

• Dressler’s syndrome

• Embolism

• Recurrence/ mitral regurgitation

heart failure

• systolic problem→ pumo failure

• heart cannot pump blood to meet metabolic demands of peripheral tissues or can only do so at elevated filling pressures

causes of HF

• coronary artery disease

• hypertension

• valvular heart disease

• cardiomyopathies

  • dilated

  • hypertrophic/obstructive

  • restrictive/ infiltrative e.g. amyloidosis

• arrythmias

• alcohol and drugs

• congenital heart disease

• high output failure→ thyrotoxicosis, anaemia

• pericardial disease

• primary right heart failure→ pulmonary hypertension

pathogenesis of heart failure

• initial injury e.g. MI

• compensatory mechanisms to preserve CO

  • frank starling

  • symp. NS

  • RAAS

• comp. mechanisms bring short term benefit but long term cardiac remodelling

• remodelling further reduces heart’s pumping ability

left heart failure

• left ventricle cannot pump blood to rest of the body

• blood backs up into lungs

  • HFrEF→ ventricle can’t squeeze effectively

  • HFpEF→ventricle is stiff and can’t relax properly to fill with blood

features of LHF

• dyspnoea

• orthopnoea

• paroxysmal nocturnal dyspnoea

• cough→ can be pink and frothy in severe cases

• fatigue/weakness

right heart failure

• right ventricle cannot pump blood effectively to lungs

• blood back up into systemic circulation

• most common cause is LHF

• cor pulmonae→ RHF caused by primary lung disease

clinical features of RHF

• peripheral oedema

• jugular venous distension

• ascites

• hepatomegaly

diagnosis of heart failure

• symptoms and signs

• investigations

  • CXR

  • ECH

  • echocardiogram

  • bloods

    • BNP

    • FBC, U&Es, LFTs, TFTs

acute HF management

• A to E assessment

• assess haemodynamic status

• diuretics

chronic HF management

• diuretics

• ACEi

• Beta blocker

• mineralocorticoid antagonist e.g. aldosterone

• manage comorbidities

• specialist management e.g. ivabradine, digoxin

complications of heart failure

• arrhythmias

• thromboembolism→ stroke, DVT, PE

• GI→ hepatic congestion and dysfunction, malabsorption

• MSK→ muscle wasting

• respiratory→ pulmonary congestion, resp. failure, pulmonary HTN