Ischaemic Heart Disease

Definition/diagnostic criteria Coronary heart disease (CHD, also known as coronary artery disease [CAD] and ischaemic heart disease [IHD]) is characterised by the development of atherosclerotic plaques within the coronary arteries which over time decrease the size of the lumen and reduce blood flow to the myocardial tissue leading to angina symptoms provoked with exertion. Acute coronary syndromes arise when the atherosclerotic plaque ruptures causing thrombosis and acute myocardial ischaemia and/or infarction.

Epidemiology CHD is one of the UK’s leading causes of death and the most common cause of premature death. It is responsible for around 66,000 deaths in the UK annually. In the UK there are 2.3 million people living with CHD and one in eight men and one in 14 women die from CHD. There remains considerable variation in mortality from CHD across the UK. Death rates are higher in Scotland than in the south of England and CHD is more prevalent in certain ethnic groups.

Diagnosis

Clinical features

  • Stable angina: A heavy, dull or tight pain in the chest which is provoked by physical exertion or stress. The pain is usually predictable and stops within a few minutes of rest. The pain may spread to other areas of the body such as the jaw, neck, arm or back. Other symptoms can include breathlessness and nausea.
  • Acute Coronary Syndrome (ACS): Severe chest pain with exertion or at rest that will usually last more than 15 minutes, associated with sweating, nausea and breathlessness. This can include MI as well as unstable angina which may be new-onset angina or a significant deterioration in previously stable angina.

Investigations

Suspected angina

  • Baseline bloods are requested to assess CVD risk – FBC, U&E, lipids, HbA1c, uACR, ECG. Referral to rapid access chest pain clinic (RACPC) or similar local services for further evaluation.
  • ECG changes in patients with CAD
  • Patients with stable angina may have a normal resting 12-lead ECG.
  • Ischaemic changes on ECG can include inverted T waves and flat or down-sloping ST segment depression.
  • Changes consistent with MI on the ECG can include ST segment elevation, left bundle branch block (LBBB), T wave inversion and pathological Q waves.
  • RACPC / Cardiology service: Investigations may include cardiac CT coronary score, CT coronary angiography (CTCA), stress echocardiography, myocardial perfusion scanning or coronary angiography to establish a diagnosis.

Suspected ACS

If patient has signs/symptoms consistent with ACS, urgent admission to A&E or hospital is required via ambulance.

Treatment

Stable angina

Patients require an explanation of stable angina and discussion of factors that provoke angina such as exertion, emotional stress, cold weather and eating a heavy meal. Patients need to be encouraged to seek help from their health care provider if they notice a significant worsening in the severity or frequency of their symptoms. General principles of management for patients with stable angina include:

  • Lifestyle advice – smoking cessation, a cardioprotective diet, help to achieve a healthy weight, increased exercise levels symptoms permitting, limiting alcohol to recommended levels or less, appropriate control of hypertension and diabetes if indicated.
  • Glyceryl trinitrate spray or tablets to treat angina attacks.
  • Beta blockers or calcium channel blockers to prevent angina attacks.
  • Occasionally further medication is required for symptom control. These medications can include isosorbide mononitrate, ivabradine, nicorandil or ranolozine.
  • Aspirin and statins are prescribed to prevent the risk of MI.
  • ACE inhibitors/ARBs should be prescribed for patients with co-existing hypertension or other comorbidities, eg, previous MI, heart failure, CKD.
  • Further intervention may be required if medications alone are not controlling symptoms
    • Percutaneous coronary intervention (PCI) – coronary arteries narrowed by atherosclerotic plaque are widened by angioplasty and the deployment of a stent.
    • Coronary artery bypass graft (CABG) – blood vessels are taken from another part of the body and used to bypass narrowed atherosclerotic coronary arteries. CABG is offered to patients on optimal medical treatment where revascularisation is appropriate but PCI is not.

If stable angina does not respond to optimal drug treatment and/or revascularisation it is important to explore the patient’s understanding of their condition and examine the impact of the symptoms on the patient’s quality of life. It is important to explain how patients can manage pain themselves, giving particular attention to the role of psychological factors in pain and the importance of developing skills to modify behaviour associated with pain.

Prognosis Stable angina is a chronic medical condition with a low but increased incidence of acute coronary events and increased mortality. More than half of patients with angina can expect to be symptom-free within 12 months with appropriate medical intervention and risk factor/lifestyle modification. Indicators of long-term prognosis include comorbidities, the extent and severity of CAD and left ventricular function.

Written by Dr Matthew Molloy, who is a GPSI in cardiology at the Westcliffe Health Innovations primary care cardiology service in Bradford, West Yorkshire

Sources

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