ISCHEMIC HEART DISEASE(IHD) sgd.pptmmmmx

Ihd

1. ISCHEMIC HEART DISEASE(IHD) DR RAJITH A JAYAN

2. Angina pectoris MI Chronic IHD  cardiac failure Sudden cardiac death

3. ANGINA Ischemia (No cell death ) ANGINA MI ECG + ECG+ Cardiac enzymes normal Cardiac enzyme eleveated

4. Angina 3 Subtypes 1.STABLE ANGINA Chest pain after exersion 2.UNSTABLE ANGINA Plaque rupture 3.PRINZMETAL ANGINA Sudden coronary vasospasm (@ rest) Only PM angina  ECG will be normal between angina On a superimposed existing atherosclerosis ECG abnormal between angina Responds to vasodialators

5. Myocardial Infarction No blood  Infarct Onset of ATP depletion = within seconds Loss of contractility= <2 min ATP will reach =50% of normal value 10 min =10% of normal value  40 min Irreversible damage = 20-40 min ( Critical time of reperfusion / Thrombolysis) Microvascular injury = >1 hr

6. Types of infarct 1.Transmural infarct Complete occlusion Infarction of the entire myocardial thickness ?? When it see Chronic atherosclerosis+Plaque change (thrombi) ECG=STEMI

7. 2.Subendocardial Infarct Infarct caused by thrombus Dissolved Rx/ SpnontaneousBefore a full thickness infarct Other causes Prolonged systemic hypotension Shock+Atherosclerosis

8. 3.Multifactorial Infarction Systemic etiology Vasculitis (Kawasaki disease) Vasospasm Drugs(Cocaine) Catecholamine

9. Postmortem analysis Biochemical>EM>Light microscopy>Gross GROSS Intital 7-8 hrs of MI there will no change TTC test Triphenyl Tertrazolium Chloride test + ve in 2-3 hrs Slice @ 1- 0.5 cm thickness TTC dye Normal myocardium= BRICK RED Infarct(Extracellular LDH)=Unstained Pale area Pure white =Old Scar

10. 1 st EM Change 0-1/2 hr = Sacrolemmal disruption Mitochondrial density reduced Myelin figures reduced

11. Light Microscopy Findings ½ hr – 4 hr => 1 st light microscopy change Waviness of fibre Vacuolisation Contraction band 4hr-3 Days => Coagulative necrosis (only pink ) 1-3 Days => Neutrophils 4h-24h-Only necrosis 24h-3D – Neut+Necrosis

12. 3-7days => Macrophage (Foamy) 7-10days => granulation tissue(capillaries) >10-14D => Collagen scar – Masson trichrome stain Collagen scar =Old infarct

13. GROSS 0-12HR = No change 12-24HR=Vague pallor & Softening 1-7Days=Yellow color 7-10Days=Central pallor with Red borders >10-14 days=White firm scar

14. MI COMPLICATION-Reperfusion injury Def: Injury to the myocardium due to fresh blood 1.Free radical induced damage Fresh blood(New ROS) Dying myocardium (antioxidants less)More damage 2.Mitochondrial damage MIAltered mitochondrial permeability More protein More ion into mitochondriaRupture out Mitochondrial membrane  Cytc Ctrigger Apoptosis

15. 3.Myocyte hyper contraction MICa2+ increased during cell deathCa2+ release from Sarcolemma Abundant Ca2+ in dying cellNew blood with ATPHypercontractionCytoskeltal damageCELL DEATH Hypercontracted muscle in microscopic highly PINK in color EOSINOPHILIC CONTRACTION BAND 4.WBC & platlets >1hrMicrovascular injurywbc+platletsThrombosis =>NO FLOW PHENOMENON

16. Complication of MI itself 1.Contractile dysfunction Large MI (>40% of LV) contractility reducedCO reducedHeart failure 2.Papillary muscle dysfunction Rupture Regurgitation

17. 3.Myocardial Rupture Risk more=3-& days post MI Ventricular free wall rupture MI Cardiac tamponade Hemopericardium Ventricular septum rupture-VSD R/F for ruptureAge >60, Ant/Lat wall, Female, ! st MI > second MI

18. 4.PERICARDITIS MI  Myocardial inflammationPericardial inflammation2-3 day recover its own B) Post MILittle bleeding blood & plasmapericardial space--.Organised(Fibrin)Fibrinous pericarditis C) MIDamage of heart muscleNew antigen (Neo antigen)Trigger antibody productionPericarditis DRESSLER SYND ( Time:week Rx Steroid) 5.MURAL THROMBUS Thromus in heart and aortaStasis of blood/Endothelial injuryThromusEmboliSystemic thromboembolic events 6.VENTRICULAR ANEURYSM

19. Cardiac enzymes My : My oglobin Time : T ROPONIN I TO : T ROPONIN T C : C K MB A : A ST LL : L DH1

20. Cardiac enzyme start peak fall Myoglobin 2hr - 24hr Troponin 2-4hr 48hr 7-10days CK-MB 2-4 hr 24hr 48-72hrs AST/SGOT <12hr 48hr 4-5days LDH1 24hr 4-5 days After 10D Myoglobin not specific –early rise early fall Troponin I > Troponin T

21. Update HFABP - Hear fatty Acid Binding Protein IMA - Ischemia Modified Albumin

22. Flipping of LDH ratio NORMAL Blood= LDH 2>>>LDH1 HEART=LDH1>>>LDH2 MI-Blood LDH 1>>>>>LDH2 Flipping ratio

23. Marker of reinfarction Is TROPONIN Serial monitoring rise by .20% from base line