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Ischemic Heart Disease

Reflects the presence of atherosclerosis in the coronary arteries (Coronary Artery Disease-CAD)


Manifestations of Ischemic Heart Disease

Angina Pectoris, Acute Myocardial Infarction, Sudden Death (likely caused by cardiac dysrhythmias)


Risk Factors for CAD

*male gender and increasing age* Hypercholesterolemia, Hypertension, Smoking Diabetes mellitus, obesity, sedentary life style, family history of premature CAD.


Caused by an imbalance between coronary blood flow (supply) and myocardial oxygen consumption (demand) which can precipitate ischemia

Angina Pectoris


What is the most common cause of myocardial ischemia?



What happens when there is an extreme imbalance between coronary blood flow (supply) and myocardial oxygen consumption (demand)?

Congestive heart failure-(CHF), electrical instability & cardiac dysrhythmias, and myocardial infarction (MI) can result.


how does Angina Pectoris present clinically?

Retrosternal chest pain (described as pressure or heaviness), discomfort typically radiates to the neck, left shoulder, left arm, or lower jaw. Usually induced by physical exertion, emotional tension, and cold weather.


how is angina pectoris diagnosed?

Electrocardiography: ST depression (> 1mm) & T wave inversion Echocardiography: wall motion abnormalities & predicts location of obstructing lesion Nuclear Stress Imaging: assesses coronary perfusion by defining vascular regions in which stress-induced coronary blood flow is limited. Can also est. LV size & function Coronary Angiography: Gold standard. Determines anatomic extent of CAD & LV function (EF).


what is the gold standard for diagnosing angina pectoris?

Coronary Angiography: Gold standard. Determines anatomic extent of CAD & LV function (EF).


what are some treatment options for angina?

Life style modification: Smoking cessation, maintenance of ideal body weight, regular aerobic exercise.

Pharmacologic therapy: Antiplatelet drugs, B-blockers, Calcium channel blockers, ACE inhibitors & Nitrates

Revascularization: Coronary Artery Bypass Grafting (CABG)& Percutaneous Transluminal Coronary Angioplasty PTCA


Nearly all MIs are caused by .....

thrombotic occlusion of a coronary artery


Stenosis > __% required to produce Angina pectoris



diagnosis of an MI requires 2 out of 3 criteria. What are they?

1) clinical history of angina pectoris

2) serial electrocardiographic changes indicative of myocardial infarction (ST segment elevation or ST depression, T wave inversion, bundle branch block)

3) rise and fall of serum cardiac enzyme markers: Troponin T or I-increase within 4 hours after myocardial injury; CK-MB is less specific


what are the symptoms of an MI?

Same as Angina pectoris On Physical exam: Anxiety, sinus tachycardia, hypotension (caused by left or right ventricular dysfunction or cardiac dysrhythmias) Moist rales representing CHF (due to LV dysfunction) Cardiac murmur may reflect ischemic mitral regurgitation.


what are some treatment options for an MI?

Aspirin IV Morphine: pain relief and decrease the stimulus to catecholamine release and increases in myocardial oxygen requirements.

Thrombolytic Therapy: Tissue plasminogen activator (t-PA, streptokinase) within 30-60 min of hospital arrival.

Coronary Angioplasty: within 1-2 hours CABG: reperfusion achieved more quickly with Thrombolytics or PTCA, emergent CABG reserved for patients who’s anatomy precludes PTCA, failed angioplasty, infarct related ventricular septal defect or MR

Adjunctive Medical Therapy: Heparin IV, Beta blockers, ACE inhibitors, nitrate therapy


what are some anesthetic considerations for MIs?

High risk patients should be optimized on preoperative anti-ischemia and anti-hypertension therapy

Control balance between myocardial oxygen supply/demand especially during induction & emergence.

Quick Intubations

Monitors: ECG, Pulmonary artery catheter, and Transesophageal echocardiography for early detection of ischemia


What are some examples of valvular heart disease?

Mitral Stenosis

Mitral Regurgitation

Mitral Valve Prolapse

Aortic Stenosis

Aortic Regurgitation

Tricuspid Regurgitation


How do you evaluate valvular heart disease?

Assess severity of disease

Assess degree of impaired contractility

Assess for the presence of associated major organ system disease (pulmonary, renal, hepatic)

Recognize compensatory mechanisms for maintaining cardiac output (> sympathetic ns activity or ventricular hypertrophy)

Define exercise tolerance to evaluate cardiac reserve

Assess for CHF

Assess for murmurs


AP valves open; so murmurs heard are AP stenosis or MT insufficiency (AS, PS, MR, TR)

systolic murmur


MT valves open; so murmurs heard are MT stenosis or AP insufficiency (MS, TS, AR, PR)

diastolic murmur


symptoms of mitral stenosis

dyspnea on exertion, orthopnea, PND from LV dysfunction (if AR and MR also present  significant LV dysfunction)


Mitral stenosis increases pressure where?

Left Atrium


how is mitral stenosis diagnosed?

by echocardiography to assess valve orifice


Transvalvular pressure gradient > ___ mmHg=severe MS

Transvalvular pressure gradient > 10 mmHg=severe MS


treatments for mitral stenosis

Prophylaxis against infective endocarditis Diuretics with mild symptoms