Coronary insufficiency
description
Transcript of Coronary insufficiency
Coronary insufficiency
พ.ต.อ.นพ.เกษม รตนสมาวงศ
13 March 2014
Content
• Definition / terminology • Cause / pathogenesis• Manifestation • Investigation• Prognosis• Treatment
คำาถามทตองตอบใหได• For underwritter
– ผเอาประกนเปน CAD หรอไม– ทราบไดอยางไร– จะตองตรวจเพมเตมอยางไร จงจะเหมาะสม– ถาเปน CAD จรง มความรนแรงเพยงใด
• For claim– ผมา claim เปน MI หรอไม– ทราบไดอยางไร / รนแรงเพยงใด
Coronary insufficiency
• Definition / terminology– Myocardial demand and supply mismatch– Myocardial ischemia– Ischemic heart disease– Coronary artery disease– Acute coronary syndrome
Anatomy or physiology
Coronary insufficiency
• Cause / pathogenesis– Atherosclerosis– Non-atherosclerosis
• Vasculitis• Embolism• Etc.
Atherosclerosis
• ปจจยเสยงของการเกดโรค–สบบหร–ความดนโลหตสง–เบาหวาน–ไขมนในเลอดสง–กรรมพนธ / ประวตครอบครว–เพศ : ชาย อาย > 45 ป หญงอาย > 55 ป
Manifestations
• กลมอาการเจบเคนอก• เหนอยงายขณะออกแรง• กลมอาการของภาวะหวใจลมเหลวทงชนด
เฉยบพลนและเรอรง• อาการเนองจากความดนโลหตตำาเฉยบพลน• อาการหมดสตหรอหวใจหยดเตน
Spectrum of disease
• Silent ischemia• Chronic stable angina• Acute coronary syndrome
– Unstable angina– Acute nonST elevation MI / NQWMI– Acute ST elevation MI / QWMI
Chest pain : Classic angina
- a dull , substernal discomfort
- radiate to left arm or neck
- associated with shortness of breath,
palpitations, sweating, nausea, vomiting
Typical angina (definite)
• Substernal chest discomfort with a characteristic quality and duration that is
• provoked by exertion or emotional stress• relieved by rest or nitroglycerine
Atypical angina ( probable ): meets 2 of the above characteristics
Noncardiac chest pain: meets < 1 of the typical angina characteristics
Investigations
• Determine myocardial ischemia• Determine myocardial scar from infarction• Determine coronary anatomy
– coronary artery stenosis ?– Degree and extent of stenosis ?
Investigations in IHD• Basic investigations
– EKG– Echocardiography– Exercise stress test
• Advanced investigation– CTA coronary artery– Dobutamine stress echo– MIBI scan– Cardiac MRI
EKG : Assessment IHD
• EKG of IHD :– inverted T wave, ST depression -> myocardial ischemia– ST elevation -> myocardial injury– abnormal Q wave -> myocardial infarction
• EKG of acute MI : – ST elevation with inverted T wave and Q wave
EKG could be normal in one-half of patients with chronic stable angina
Abnormal EKG in absent of clinical heart disease
• QS complex in AVL,V1-2 . QS or QR complex in III,AVF.
• Tall R inV1 and V2. High voltage R wave over left ventricle
• ST elevation : early repolarization• Inverted T wave : nonspecific T wave
changes
Abnormal EKG in absent of clinical heart disease
• Nonspecific ST and T wave changes are the most common EKG abnormality
• About 50% of abnormal tracings recorded in a general hospital population
• most common cause of “ iatrogenic EKG heart disease”
• must always be correlated with all available clinical and laboratory information
Information from Echocardiography
• Cardiac valves morphology & chamber enlargement , hypertrophy ?
• LV systolic and diastolic function & regional wall motion abnormality
• Valves function : stenosis & regurgitation• Pericardial effusion, vegetation & thrombus• congenital heart disease : ASD,VSD,PDA• Aortic dissection
Echocardiography in IHD
• Assess global LV function and RWMA– Myocardial ischemia -> hypokinesia– Myocardial infarction -> akinesia /
dyskinesia or aneurysm• Could be normal in chronic stable
angina• abnormal in acute / recent or old MI
Exercise stress test
• For Dx IHD – Overall sensitivity about 75% ( negative test
not excluded )• For assess IHD : high / low risk• Limitation in young, middle age female,
abnormal baseline EKG ( false positive is high )
Exercise stress test
• Specificity is less in women than men• lower prevalence and extent of CAD in
young and middle-aged women & catecholamine effect
• LVH, LBBB, WPW syndrome : need exercise or pharmacologic imaging study
Exercise stress test
• Result of EST– Positive VS Negative– Equivocal– Inadequate– assess functional capacity : low,moderate
or high workload– assess hemodynamic response
Exercise stress test
• Assess myocardial ischemia• In case of old MI
– EST could be positive or negative– Negative EST not exclude old MI
Exercise or pharmacologic stress echocardiography
• Higher specificity• More extensive evaluation of cardiac
anatomy and function• Greater convenience,efficacy and
availability• Lower cost ( compare with stress
perfusion imaging )
Stress perfusion imaging
• MIBI scan / Thallium• Higher technical success rate• Higher sensitivity• Better accuracy in evaluating possible
ischemia when multiple rest LV wall motion abnormalities are present
Calcium score
Calcium score : use for risk stratification
CTA coronary artery
CTA coronary artery : for R/O CAD
Cardiac MRI• Useful in IHD and other cardiovascular disease• In IHD : use for assess myocardial function, myocardial
ischemia , viable myocardium and myocardial infarction
Coronary angiography
• Invasive test• Gold standard for Dx IHD• single or double or tripple vessel disease• Involve left main ? • % of stenosis• Assess LV function by LV ventriculogram
Acute MI
• Criteria for diagnosis– Chest pain : Angina– EKG changes : evidence of myocardial ischemia
and injury– Cardiac biomarkers : rising of troponins, CK-MB
Timing of cardiac biomarkers measurementis important for diagnosis !!!
Biomarkers in Acute Coronary Syndrome Detection, sensitivity and specificity for AMI
2 - 3 d7 - 14 d7 - 10 d1 - 2 d8 -12 h
Duration of Detection
++++++++++++++++
Sensitivity
4 – 6 h3 – 4 h3 – 4 h2 – 3 h
1.5 – 2 h
First Detection
++CK Total++++Troponin T++++Troponin I+++CK-MB+Myoglobin
SpecificityMarkers
Successful reperfusion in AMI patients accelerates the cardiac marker release.
*TIMI: Thrombolysis in Myocardial InfarctionFrench JK, White HD. Clinical implications of the new definition of myocardial infarction. Heart (2004) 90: 99 –106
Prognosis
• เปนโรคเรอรง : ไมหายขาด• สาเหตการเสยชวต : Heart failure / cardiac
arrhythmias• ความรนแรงหรอการพยากรณโรคขนกบ
– LV function / previous MI ?– Extent of disease / area of ischemia– High risk criteria from noninvasive test
การรกษา IHD
• การรกษาดวยยา • การรกษาดวยวธ Balloon • การรกษาดวยการผาตด Bypass