1 1 ischemic heart disease (ihd – coronary heart disease) introduction to primary care: a course...
TRANSCRIPT
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1 1
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 11417Tel: 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.
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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
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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 )
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What characteristics of the chest pain might make you more concerned for cardiac chest pain?
• Location• Associated
Symptoms• Quality• Chronology• Onset
• Duration• Intensity• Exacerbating• Relieving• Situation
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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….
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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
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What would be the differential diagnosis for
chest pain?
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Life threatening Causes Non-life threatening CausesCardiovascular(16%):• Myocardial infarct.• Angina.•Thoracic aortic dissection.
Pulmonary (5%):•Pulmonary embolus.•Pulmonary infarction.•Tension pneumothorax.•Pneumonia.•Pleurisy.
Chest wall (33%):•Trauma•Fracture•Costo-chondritis.•Musculoskeletal.
•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
• Age > 45 (male) and >55 (female).• Smoking.• Family history.• Hyperlipidemia. • Diabetes. • Hypertension.• Obesity.• Sedentary life style.• Anxiety.• Drug addiction.• Past History.
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Any tests that might help in diagnosis?
•History and Examination
•ECG
•Cardiac Enzymes
•Chest x-ray.
•Upper GI endoscopy.
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Cont…
• ECGST 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
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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
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Risk CategoryRisk CategoryLDL GoalLDL Goal(mg/dL)(mg/dL)
LDL Level at LDL Level at Which to Initiate Which to Initiate
Therapeutic Therapeutic Lifestyle Changes Lifestyle Changes
(TLC) (mg/dL)(TLC) (mg/dL)
LDL Level at Which LDL Level at Which to Considerto Consider
Drug Therapy Drug Therapy (mg/dL)(mg/dL)
CHD or CHD Risk CHD or CHD Risk EquivalentsEquivalents
(10-year risk >20%)(10-year risk >20%)
Very high riskVery high risk
<<100100
< < 7070) ) VHRPVHRP((
100100 130 130 (100(100––129: drug 129: drug
optional)optional)
<) <) 100100 : :drug optionaldrug optional((
22 + +Risk Factors Risk Factors (10-year risk (10-year risk 20%)20%)
))moderately high moderately high risk ptrisk pt( (
1010--year risk < 10%year risk < 10%
<<130130
<<100100))theraputic theraputic optionoption((
<<130130
100100
130130
1010--year risk 10year risk 10––20%: 20%: 130130
100-129100-129
1010--year risk <10%: year risk <10%: 160160
00––11 Risk FactorRisk Factor <<160160 160160
190 190 (160(160––189: LDL-189: LDL-lowering drug lowering drug
optional)optional)
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• 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
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Initial Approach• ABC assessment
• 100% Oxygen
• Aspirine
• Nitroglycerine
• IV access
• Morphine
• Monitoring
• ECG quickly
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Action Plan
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Action Plan
Source: http://www.aafp.org/afp/20050701/119.html
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Referral
Refer urgently all the serious conditions with chest pain:
• Cardiac causes.• Esophageal spasm.• Pulmonary embolism.• Any other cases not responding to usual treatment.
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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 kinase-MB 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
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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
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