Ischaemic heart disease

Ischaemic heart disease
Classification and external resources
ICD-10	I20-I25
ICD-9	410-414
DiseasesDB	8695
eMedicine	med/1568
MeSH	D017202

Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease characterized by ischaemia (reduced blood supply) of the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking, hypercholesterolaemia (high cholesterol levels), diabetes, and hypertension (high blood pressure), and is more common in men and those who have close relatives with ischaemic heart disease.

Symptoms of stable ischaemic heart disease include angina (characteristic chest pain on exertion) and decreased exercise tolerance. Unstable IHD presents itself as chest pain or other symptoms at rest, or rapidly worsening angina. Diagnosis of IHD is with an electrocardiogram, blood tests (cardiac markers), cardiac stress testing or a coronary angiogram. Depending on the symptoms and risk, treatment may be with medication, percutaneous coronary intervention (angioplasty) or coronary artery bypass surgery (CABG).

It is the most common cause of death in most Western countries, and a major cause of hospital admissions.^[1] There is limited evidence for population screening, but prevention (with a healthy diet and sometimes medication for diabetes, cholesterol and high blood pressure) is used both to prevent IHD and to decrease the risk of complications.

The medical history distinguishes between various alternative causes for chest pain (such as dyspepsia, musculoskeletal pain, pulmonary embolism). As part of an assessment of the three main presentations of IHD, risk factors are addressed. These are the main causes of atherosclerosis (the disease process underlying IHD): age, male sex, hyperlipidaemia (high cholesterol and high fats in the blood), smoking, hypertension (high blood pressure), diabetes, and the family history.^[2]

Signs and symptoms

Ischaemic heart disease may be present with any of the following problems:

• Angina pectoris (chest pain on exertion, in cold weather or emotional situations)
• Acute chest pain: acute coronary syndrome, unstable angina or myocardial infarction^[3] ("heart attack", severe chest pain unrelieved by rest associated with evidence of acute heart damage)
• Heart failure (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle)

The medical history distinguishes between various alternative causes for chest pain (such as dyspepsia, musculoskeletal pain, pulmonary embolism). As part of an assessment of the three main presentations of IHD, risk factors are addressed. These are the main causes of atherosclerosis (the disease process underlying IHD): age, male sex, hyperlipidaemia (high cholesterol and high fats in the blood), smoking, hypertension (high blood pressure), diabetes, and the family history.^[2]

Diagnosis

The diagnosis of ischaemic heart disease underlying particular symptoms depends largely on the nature of the symptoms. The first investigation is an electrocardiogram (ECG/EKG), both for "stable" angina and acute coronary syndrome. An X-ray of the chest and blood tests may be performed.

Myeloperoxidase has been proposed as a biomarker.^[4]

Stable angina

Main article: angina pectoris

In "stable" angina, chest pain with typical features occurring at predictable levels of exertion, various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery.

Acute chest pain

Main articles: acute coronary syndrome and myocardial infarction

Diagnosis of acute coronary syndrome generally takes place in the emergency department, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI), and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage (infarction), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates admission to hospital, and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias - irregularities in the heart rate).

Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.

Heart failure

Main article: heart failure

In patients with heart failure, stress testing or coronary angiography may be performed to identify and treat underlying coronary artery disease.

Pathogenesis

Main article: coronary artery disease

The disease process underlying most ischaemic heart disease is atherosclerosis of the coronary arteries. The arteries become "furred up" by fat-rich deposits in the vessel wall (plaques).

Stable angina is due to inability to supply the myocardium (heart muscle) with sufficient blood in situations of increased demand for oxygen, such as exertion.

Unstable angina, STEMI and NSTEMI are attributed to "plaque rupture", where one of the plaques gets weakened, develops a tear, and forms an adherent blood clot that either obstructs blood flow or floats further down the blood vessel, causing obstruction there.

Prevention

Various treatments are offered in people deemed to be at high risk of coronary artery disease. These include control of cholesterol levels in those with known high cholesterol, smoking cessation, and control of high blood pressure.

Management

In stable IHD, antianginal drugs may be used to reduce the rate of occurrence and severity of angina attacks. Treatments for acute coronary syndrome and established coronary artery disease is discussed above in "diagnosis". Revascularization for acute coronary syndrome has a significant mortality benefit.^[5] Recent evidence suggests that revascularization for stable ischaemic heart disease may also confer a mortality benefit over medical therapy alone.^[6]

Treatment of coronary artery disease includes addressing "modifiable" risk factors. This includes suppression of cholesterol (usually with statins), even in those with statistically normal cholesterol levels, control of blood pressure, blood sugars (if diabetic), regular exercise and a healthy diet. Smokers are encouraged to stop smoking.

Epidemiology

IHD is the leading cause of death for both men and women in the US and other industrialized countries. It may affect individuals at any age but is most common in older individuals. Males are affected more often than females however the rates equalize between men and women following menopause.

Disability-adjusted life year for ischaemic heart disease per 100,000 inhabitants in 2004.^[7]

  no data

  less than 350

  350-700

  700-1050

  1050-1400

  1400-1750

  1750-2100

  2100-2450

  2450-2800

  2800-3150

  3150-3500

  3500-4000

  more than 4000

See also

• Infarct Combat Project

References

1. ^ World Health Organization Department of Health Statistics and Informatics in the Information, Evidence and Research Cluster (2004). The global burden of disease 2004 update. Geneva: WHO. ISBN 9241563710. 
2. ^ ^{a b} Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson (2007). Robbins Basic Pathology (8th ed.). Philadelphia: Saunders. pp. 345. ISBN 1-4160-2973-7. 
3. ^ Mallinson, T (2010). "Myocardial Infarction". Focus on First Aid (15): 15. http://www.focusonfirstaid.co.uk/Magazine/issue15/index.aspx. Retrieved 2010-06-08. 
4. ^ Loria V, Dato I, Graziani F, Biasucci LM (2008). "Myeloperoxidase: a new biomarker of inflammation in ischemic heart disease and acute coronary syndromes". Mediators Inflamm. 2008: 135625. doi:10.1155/2008/135625. PMC 2276594. PMID 18382609. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2276594. 
5. ^ Braunwald E, Antman EM, Beasley JW, et al. (October 2002). "ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)". Circulation 106 (14): 1893–900. doi:10.1161/01.CIR.0000037106.76139.53. PMID 12356647. http://circ.ahajournals.org/cgi/content/full/106/14/1893. 
6. ^ Jeremias A, Kaul S, Rosengart TK, Gruberg L, Brown DL (2009). "The impact of revascularization on mortality in patients with nonacute coronary artery disease". Am J Med 122 (2): 152–161. doi:10.1016/j.amjmed.2008.07.027. PMID 19185092. 
7. ^ "WHO Disease and injury country estimates". World Health Organization. 2009. http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html. Retrieved Nov. 11, 2009.