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Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease
Disease

A disease or medical condition is an abnormal condition of an organism that impairs bodily functions, associated with specific symptoms and Medical signs....
 characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease
Coronary heart disease

Coronary artery disease is the end result of the accumulation of atheroma within the walls of the Coronary circulation that supply the myocardium with oxygen and nutrients....
 (atherosclerosis
Atherosclerosis

Atherosclerosis is a syndrome affecting artery blood vessels. It is a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by low density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoprot...
 of the coronary arteries). Its risk increases with age, smoking
Tobacco smoking

Tobacco smoking is the inhalation of smoke from burned dried or cured leaves of the tobacco plant, most often in the form of a cigarette. People may smoke casually for pleasure, habitually to satisfy an addiction to the nicotine present in tobacco and to the act of smoking, or in response to social pressure....
, hypercholesterolaemia (high cholesterol
Cholesterol

Cholesterol is a lipidic, waxy alcohol found in the cell membranes and transported in the blood plasma of all animals. It is an essential component of mammalian cell membranes where it is required to establish proper membrane permeability and membrane fluidity....
 levels), diabetes
Diabetes mellitus

Diabetes mellitus , often referred to simply as diabetes , is a syndrome of disordered metabolism, usually due to a combination of genetic disorder and environmental causes, resulting in abnormally high blood sugar levels ....
, hypertension
Hypertension

Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated....
 (high blood pressure) and is more common in men and those who have close relatives with ischaemic heart disease.

Symptoms of stable ischaemic heart disease include angina
Angina

Angina pectoris, commonly known as angina, is severe chest pain due to ischemia of the myocardium, generally due to obstruction or spasm of the coronary circulation ....
 (characteristic chest pain
Chest pain

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the chest pain is non-cardiac in origin this is often a diagnosis of exclusion made after ruling out more serious causes of pain....
 on exertion) and decreased exercise tolerance.






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Encyclopedia


Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease
Disease

A disease or medical condition is an abnormal condition of an organism that impairs bodily functions, associated with specific symptoms and Medical signs....
 characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease
Coronary heart disease

Coronary artery disease is the end result of the accumulation of atheroma within the walls of the Coronary circulation that supply the myocardium with oxygen and nutrients....
 (atherosclerosis
Atherosclerosis

Atherosclerosis is a syndrome affecting artery blood vessels. It is a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by low density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoprot...
 of the coronary arteries). Its risk increases with age, smoking
Tobacco smoking

Tobacco smoking is the inhalation of smoke from burned dried or cured leaves of the tobacco plant, most often in the form of a cigarette. People may smoke casually for pleasure, habitually to satisfy an addiction to the nicotine present in tobacco and to the act of smoking, or in response to social pressure....
, hypercholesterolaemia (high cholesterol
Cholesterol

Cholesterol is a lipidic, waxy alcohol found in the cell membranes and transported in the blood plasma of all animals. It is an essential component of mammalian cell membranes where it is required to establish proper membrane permeability and membrane fluidity....
 levels), diabetes
Diabetes mellitus

Diabetes mellitus , often referred to simply as diabetes , is a syndrome of disordered metabolism, usually due to a combination of genetic disorder and environmental causes, resulting in abnormally high blood sugar levels ....
, hypertension
Hypertension

Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated....
 (high blood pressure) and is more common in men and those who have close relatives with ischaemic heart disease.

Symptoms of stable ischaemic heart disease include angina
Angina

Angina pectoris, commonly known as angina, is severe chest pain due to ischemia of the myocardium, generally due to obstruction or spasm of the coronary circulation ....
 (characteristic chest pain
Chest pain

In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the chest pain is non-cardiac in origin this is often a diagnosis of exclusion made after ruling out more serious causes of pain....
 on exertion) and decreased exercise tolerance. Unstable IHD presents itself as chest pain or other symptoms at rest, or rapidly worsening angina. Diagnosis of IHD is with an electrocardiogram
Electrocardiogram

An electrocardiogram is a recording of the electricity activity of the heart over time produced by an electrocardiograph, usually in a Non-invasive recording via skin electrodes....
, blood test
Blood test

A blood test is a medical laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick....
s (cardiac markers), cardiac stress test
Cardiac stress test

A cardiac stress test is a medical test that indirectly reflects artery blood flow to the heart during physical exercise. When compared to blood flow during rest, the test reflects imbalances of blood flow to the heart's left ventricular muscle tissue ? the part of the heart that performs the greatest amount of work pumping blood....
ing or a coronary angiogram
Coronary catheterization

A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter....
. Depending on the symptoms and risk, treatment may be with medication
Medication

A pharmaceutical drug, also referred to as medicine or medicament, can be loosely defined as any substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease....
, percutaneous coronary intervention
Percutaneous coronary intervention

Percutaneous coronary intervention , commonly known as coronary angioplasty or simply angioplasty, is a therapeutic procedure to treat the stenosis coronary artery of the heart found in coronary heart disease....
 (angioplasty) or coronary artery bypass surgery
Coronary artery bypass surgery

Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgery performed to relieve Angina pectoris and reduce the risk of death from Coronary heart disease....
 (CABG).

It is the most common cause of death in most Western countries, and a major cause of hospital admissions. There is limited evidence for population screening, but prevention
Prevention (medical)

In medicine, prevention is any activity which reduces the burden of mortality or morbidity from disease. This takes place at primary, secondary and tertiary prevention levels....
 (with a healthy diet and sometimes medication for diabetes, cholesterol and high blood pressure) is used both to prevent IHD and to decrease the risk of complications.

Signs and symptoms

Ischaemic heart disease may present with any of the following problems:
  • Angina pectoris (chest pain
    Chest pain

    In medicine, chest pain is a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the chest pain is non-cardiac in origin this is often a diagnosis of exclusion made after ruling out more serious causes of pain....
     on exertion, in cold weather or emotional situations)
  • Acute chest pain: acute coronary syndrome
    Acute coronary syndrome

    An acute coronary syndrome is a set of signs and symptoms related to the heart. ACS is compatible with a diagnosis of acute myocardial ischemia, but it is not pathognomonic....
    , unstable angina
    Unstable angina

    Unstable angina is a type of angina pectoris that is irregular. It is a type of acute coronary syndrome.It can be difficult to distinguish from non?Q-wave myocardial infarction....
     or myocardial infarction
    Myocardial infarction

    Myocardial infarction , commonly known as a heart attack, occurs when the Blood flow to part of the heart is interrupted. This is most commonly due to occlusion of a coronary artery following the rupture of a Vulnerable plaque, which is an unstable collection of lipids and white blood cells in the wall of an artery....
     ("heart attack", severe chest pain unrelieved by rest associated with evidence of acute heart damage)
  • Heart failure (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle)


The medical history
Medical history

The medical history or anamnesis J - jaundice T - tuberculosis H - hypertension & heart disease R - rheumatic fever...
 distinguishes between various alternative causes for chest pain (such as dyspepsia
Dyspepsia

Dyspepsia , popularly known as indigestion, meaning hard or difficult digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating....
, musculoskeletal pain, pulmonary embolism
Pulmonary embolism

Pulmonary embolism is a blockage of the pulmonary artery or one of its branches, usually occurring when a deep vein thrombosis becomes dislodged from its site of formation and travels, or embolism, to the pulmonary artery blood supply of one of the lungs....
). As part of an assessment of the three main presentations of IHD, risk factor
Risk factor

A risk factor is a variable associated with an increased risk of disease or infection. Risk factors are Correlation and not necessarily Causality, because correlation does not imply causation....
s are addressed. These are the main causes of atherosclerosis
Atherosclerosis

Atherosclerosis is a syndrome affecting artery blood vessels. It is a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by low density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoprot...
 (the disease process underlying IHD): age, male sex, hyperlipidaemia (high cholesterol
Cholesterol

Cholesterol is a lipidic, waxy alcohol found in the cell membranes and transported in the blood plasma of all animals. It is an essential component of mammalian cell membranes where it is required to establish proper membrane permeability and membrane fluidity....
 and high fats in the blood), smoking
Tobacco smoking

Tobacco smoking is the inhalation of smoke from burned dried or cured leaves of the tobacco plant, most often in the form of a cigarette. People may smoke casually for pleasure, habitually to satisfy an addiction to the nicotine present in tobacco and to the act of smoking, or in response to social pressure....
, hypertension
Hypertension

Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated....
 (high blood pressure), diabetes
Diabetes mellitus

Diabetes mellitus , often referred to simply as diabetes , is a syndrome of disordered metabolism, usually due to a combination of genetic disorder and environmental causes, resulting in abnormally high blood sugar levels ....
, and the family history
Family history (medicine)

In medicine, a family history consists of information about disorders that a patient's direct blood relatives have suffered from. Genealogy typically includes very little of the medical history of the family, but the medical history could be considered a specific subset of the total history of a family....
.

Diagnosis

The diagnosis of ischemic heart disease underlying particular symptoms depends largely on the nature of the symptoms. The first investigation is an electrocardiogram
Electrocardiogram

An electrocardiogram is a recording of the electricity activity of the heart over time produced by an electrocardiograph, usually in a Non-invasive recording via skin electrodes....
 (ECG/EKG), both for "stable" angina and acute coronary syndrome. An X-ray of the chest
Chest X-ray

A chest X-ray, commonly Abbreviation CXR, is a projection radiograph , taken by a radiographer, of the thorax which is used to diagnose problems with that area....
 and blood test
Blood test

A blood test is a medical laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick....
s may be performed.

Myeloperoxidase
Myeloperoxidase

Myeloperoxidase is a peroxidase enzyme most abundantly present in neutrophil granulocytes . It is a lysosome protein stored in azurophilic granules of the neutrophil....
 has been proposed as a biomarker.

Stable angina


In "stable" angina, chest pain with typical features occurring at predictable levels of exertion, various forms of cardiac stress test
Cardiac stress test

A cardiac stress test is a medical test that indirectly reflects artery blood flow to the heart during physical exercise. When compared to blood flow during rest, the test reflects imbalances of blood flow to the heart's left ventricular muscle tissue ? the part of the heart that performs the greatest amount of work pumping blood....
s may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography
Echocardiography

An echocardiogram, often referred to in the medical community as a cardiac ECHO or simply an ECHO, is a sonography of the heart. Also known as a cardiac ultrasound, it uses standard ultrasound techniques to image two-dimensional slices of the heart....
 (using ultrasound
Medical ultrasonography

Diagnostic sonography is an ultrasound-based diagnostic medical imaging technique used to visualize subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions....
 of the heart) or scintigraphy (using uptake of radionuclide
Radionuclide

A radionuclide is an atom with an unstable Atomic nucleus, which is a nucleus characterized by excess energy which is available to be imparted either to a newly-created radiation particle within the nucleus, or else to an atomic electron ....
 by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography
Coronary catheterization

A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter....
 may be used to identify stenosis
Stenosis

A stenosis is an abnormal narrowing in a blood vessel or other tubular Organ or structure.It is also sometimes called a "stricture" .The term "coarctation" is synonymous, but is commonly used only in the context of aortic coarctation....
 of the coronary arteries and suitability for angioplasty
Angioplasty

Angioplasty is the technique of mechanically widening a narrowed or obstructed blood vessel; typically as a result of atherosclerosis. Tightly folded balloons are passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure ....
 or bypass surgery
Coronary artery bypass surgery

Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgery performed to relieve Angina pectoris and reduce the risk of death from Coronary heart disease....
.

Acute chest pain


Diagnosis of acute coronary syndrome generally takes places in the emergency department
Emergency department

The emergency department , sometimes termed the emergency room , emergency ward , accident & emergency department or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injury, some of which may be Medical emergency and requiri...
, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment
Electrocardiogram

An electrocardiogram is a recording of the electricity activity of the heart over time produced by an electrocardiograph, usually in a Non-invasive recording via skin electrodes....
", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI), and is treated as an emergency with either urgent coronary angiography
Coronary catheterization

A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter....
 and percutaneous coronary intervention
Percutaneous coronary intervention

Percutaneous coronary intervention , commonly known as coronary angioplasty or simply angioplasty, is a therapeutic procedure to treat the stenosis coronary artery of the heart found in coronary heart disease....
 (angioplasty with or without stent
Stent

In medicine, a stent is a man-made 'tube' inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction....
 insertion) or with thrombolysis
Thrombolysis

Thrombolysis is the breakdown of thrombosis by pharmacology means. It is colloquially referred to as clot busting for this reason. It works by stimulating fibrinolysis by plasmin through infusion of analogs of tissue plasminogen activator, the protein that normally activates plasmin....
 ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage (infarction
Infarction

In medicine, an infarction results in the death of a macroscopic area of tissue in an organ due to loss of adequate blood supply. This dead tissue is then known as necrosis....
), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates admission to hospital, and close observation on a coronary care unit
Coronary care unit

A coronary care unit is a hospital ward specialized in the care of patients with myocardial infarctions, unstable angina and various other cardiac conditions that require continuous monitoring and treatment....
 for possible complications (such as cardiac arrhythmia
Cardiac arrhythmia

Cardiac arrhythmia is a term for any of a large and heterogeneous group of conditions in which there is abnormal Electrical conduction system of the heart in the heart....
s - irregularities in the heart rate).

Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.

Heart failure


In patients with heart failure, stress testing or coronary angiography may be performed to identify and treat underlying coronary artery disease.

Pathogenesis


The disease process underlying most ischemic heart disease is atherosclerosis
Atherosclerosis

Atherosclerosis is a syndrome affecting artery blood vessels. It is a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by low density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoprot...
 of the coronary arteries. The arteries become "furred up" by fat-rich deposits in the vessel wall (plaques).

Stable angina is due to inability to supply the myocardium (heart muscle) with sufficient blood in situations of increased demand for oxygen, such as exertion.

Unstable angina, STEMI and NSTEMI are attributed to "plaque rupture", where one of the plaques gets weakened, develops a tear, and forms an adherent blood clot
Thrombus

A thrombus , or blood clot, is the final product of the blood coagulation step in hemostasis. It is achieved via the aggregation of platelets that form a platelet plug, and the activation of the humoral coagulation system ....
 that either obstructs blood flow or floats further down the blood vessel, causing obstruction there.

Treatment

In stable IHD, antianginal
Antianginal

An antianginal is any Medication used in the treatment of angina pectoris, a symptom of coronary heart disease....
 drugs may be used to reduce the rate of occurrence and severity of angina attacks. Treatments for acute coronary syndrome and established coronary artery disease is discussed above in "diagnosis". Revascularization for acute coronary syndrome has a significant mortality benefit. Recent evidence suggests that revascularization for stable ischemic heart disease may also confer a mortality benefit over medical therapy alone.

Treatment of coronary artery disease includes addressing "modifiable" risk factors. This includes suppression of cholesterol (usually with statin
Statin

The statins are a class of drugs that lower cholesterol levels in people with or at risk of cardiovascular disease.They lower cholesterol by inhibiting the enzyme HMG-CoA reductase, which is the rate-limiting step enzyme of the mevalonate pathway of cholesterol synthesis....
s), even in those with statistically normal cholesterol levels, control of blood pressure
Blood pressure

Blood pressure is the pressure exerted by circulating blood on the walls of blood vessels, and constitutes one of the principal vital signs. The pressure of the circulating blood decreases as it moves away from the heart through artery and capillary, and toward the heart through veins....
, blood sugar
Blood sugar

Blood sugar concentration, or glucose level, refers to the amount of glucose present in a mammal's blood. Normally, the blood glucose level is maintained at a Reference_ranges_for_blood_tests#Electrolytes_and_Metabolites between about 4 and 6 mM ....
s (if diabetic), regular exercise and a healthy diet. Smokers are encouraged to stop smoking.

Prevention

Various treatments are offered in people deemed to be at high risk of coronary artery disease. These include control of cholesterol levels in those with known high cholesterol, smoking cessation
Smoking cessation

Smoking cessation is the action leading towards the discontinuation of the consumption of a smoked substance, keenly tobacco, however it may encompass cannabis smoking and other substances as well....
, and control of high blood pressure.