Transcript Document

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 11417
Tel: 4912326 – Fax: 4970847
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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
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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 Causes
Cardiovascular(16%):
• Myocardial infarct.
• Angina.
•Thoracic aortic dissection.
Chest wall (33%):
•Trauma
•Fracture
•Costo-chondritis.
•Musculoskeletal.
Pulmonary (5%):
•Pulmonary embolus.
•Pulmonary infarction.
•Tension pneumothorax.
•Pneumonia.
•Pleurisy.
•Gastrointistinal(20%):
•Esophageal spasm
•Esophagitis.
•Gall bladder disease.
•Peptic ulcer disease.
•pancreatitis
Psychatric (9%):
• Anxiety.
Spinal dysfunction:
• Cervical disease.
Infections (rare):
• Herpes Zoster.
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The risk factors for CAD
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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…
• ECG
ST 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 Category
CHD or CHD Risk
Equivalents
(10-year risk
>20%)
Very high risk
2+ Risk Factors
(10-year risk 20%)
(moderately high
risk pt )
10-year risk < 10%
0–1 Risk Factor
LDL Goal
(mg/dL)
<100
LDL Level at Which
to Initiate
Therapeutic
Lifestyle Changes
(TLC) (mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
(< 100: drug
optional)
<70 (VHRP)
10-year risk 10–
20%: 130
100-129
<130
<100(theraputic
option)
100
<130
130
10-year risk <10%:
160
160
190
(160–189: LDLlowering drug
optional)
<160
• 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
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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:
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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 kinaseMB 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