Ischemic Heart Disease

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CLINICAL DESCRIPTION

Condition in which there is inadequate blood and oxygen supply to any portion of the myocardium. Can be stable angina, unstable angina, or myocardial infarction (acute coronary syndrome).

Risk factors: Hypertension, Diabetes mellitus, smoking, alcohol, old age, hyperlipidemia, family history of ischemic heart disease.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Central crashing chest pain (worse on exertion) +/-radiation to left arm/jaw/neck + nausea/vomiting
  • Heaviness feeling on the chest
  • Shortness of breath and palpitations
  • Sweating
  • -/+ signs of pulmonary edema if LVF

Note: old and diabetic patients may have silent myocardial infarction (with no chest pain)

INVESTIGATIONS

  • FBC, Cardiac enzymes (CK, CK-MB, Troponin, AST, LDH), U+E+Creatinine, RBS, Lipogram, ECG, CXR, Echocardiogram

TREATMENT 

General measures

Minimize risk factors by:

  • Weight reduction (if obese)
  • Control of hypertension
  • Control of diabetes
  • Stop smoking

Address other factors such as:

  • High blood cholesterol
  • Stressful lifestyle
  • Excessive alcohol intake
  • Encourage monitored regular moderate exercise

STABLE ANGINA (INFREQUENT ATTACKS)

CLINICAL DESCRIPTION

Angina is due to poor blood flow through the blood vessels in the heart (coronary arteries). It is chest pain or discomfort that most often occurs with activity or emotional stress.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Central chest pain {squeezing, heavy discomfort} with radiation to the left arm on exertion or at rest lasting 2-5 minutes, crescendo and decrescendo pattern.

INVESTIGATIONS

  • As in ischemic heart disease section above

TREATMENT

PHARMACOLOGICAL 

  • Give Aspirin 150 mg daily

Acute relief of Angina

  • Give Glyceryl Trinitrate 0.5 mg sublingually as required.
  • Maximum 3 tablets per 15 minutes
  • Deteriorates on storage: keep tablets in original container for no more than 3 months after opening
  • Alternatively use Isosorbide Dinitrate 5-10mg sublingually as required instead of Glyceryl Trinitrate

Long term management

  • Atenolol 50 mg 12 hourly (if not asthmatic)
  • Amlodipine 5-10mg daily or Nifedipine 10-20 mg daily to replace or be cautiously added to Atenolol
  • If pain continues despite the above treatment refer to Medical Specialist

 Red flags

  • Unstable angina, non-ST segment myocardial infarction
  • Central chest pain as above lasting more than 10 minutes and has a crescendo pattern
  • Acute myocardial Infarction (ST segment elevation)
  • Typical angina pain plus most patients being restless, anxious, pale and with cold extremities

Treatment

  • Nitrates and Morphine 2-5mg IV for pain control if there is no hypotension.

Note: Urgently discuss these patients with medical specialist!