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Ischemic Heart Disease ( IHD – coronary Heart Disease)

Ischemic Heart Disease ( IHD – coronary Heart Disease). Introduction to Primary Care: a course of the Center of Post Graduate Studies i n FM. PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. 1. objectives:. At the end of this session the trainee will be able to

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Ischemic Heart Disease ( IHD – coronary Heart Disease)

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  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 11417 Tel: 4912326 – Fax: 4970847 1

  2. 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. • appropriatlyuse of specialty referral.

  3. 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

  4. 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 )

  5. 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

  6. 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….

  7. 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

  8. What would be the differential diagnosis for chest pain?

  9. ..

  10. 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.

  11. Any tests that might help in diagnosis? • History and Examination • ECG • Cardiac Enzymes • Chest x-ray. • Upper GI endoscopy.

  12. 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

  13. 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

  14. 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

  15. Initial Approach • ABC assessment • 100% Oxygen • Aspirine • Nitroglycerine • IV access • Morphine • Monitoring • ECG quickly

  16. Action Plan

  17. Action Plan Source: http://www.aafp.org/afp/20050701/119.html

  18. Referral Refer urgently all the serious conditions with chest pain: Cardiac causes. Esophageal spasm. Pulmonary embolism. Any other cases not responding to usual treatment.

  19. 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

  20. 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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