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Major risk factor for ischemic heart disease are:
◾️Diabetes Mellitus
◾️Hyperlipidemia
◾️Hypertension
◾️Smoking
◾️Family history of premature coronary artery disease or myocardial infarction in first-degree relative

The major difference between stable and unstable angina is that:
the first come with exertion
and the second at rest. ❗️

Physical examination is not reliable to diagnose Ischemic Heart Disease (IHD) as it can be normal❗️

Most reliable diagnostic methods for IHD are:

🔺Resting ECG.

🔺Stress ECG "highest sensitivity”.

🔺Stress echocardiography.

Cardiac catheterization is the most accurate to know a specific cardiac diagnose 💢

Coronary angiography is
▫️Most known to show the presence & severity of coronary artery diseases (CAD).

▫️Mainly to know if revascularization is needed.

▫️If it shows coronary stenosis 70<, then most likely it is significant.

Ischemic Heart Disease management(IHD):
⁃ Medical therapy:
▫️Aspirin
▫️ β-Blockers
▫️Nitrates
▫️Calcium channel blockers
⁃ Revascularation

Management of Ischemic Heart Disease decision:
🔺 For all patient:
⁃ Risk factor modification and aspirin
🔺 Mild disease:
⁃ Nitrate & B-blocker
⁃ If symptoms continue: calcium channel blocker
🔺 Moderate disease (normal EF,moderate angina,two vessel diseases):
If above regimen not working: revascularization
🔺 Severe disease(decreased EF, severe angina, and three-vessel/left main or left anterior descending disease):
Coronary angiography & consider CABG


Unstable Angina Pectoris indicates
stenosis that worsen by thrombus, hemorrhage, or plaque rupture.

Diagnose by
excluding MI & doing ECG stress testing.

Treated aggressively by
▫️ Aspirin

▫️ Clopidogrel

▫️ B-Blocker

◽️ Low–molecular-weight heparin (LMWH) (Enoxaparin drug of choice)

◽️ Nitrate (1st line)

◽️ Oxygen (if hypoxic)

◽️ Glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban)

◽️ Morphine

Does not work then do Cardiac catheterization/revascularization

Mnemonic for unstable angina
treatment:
Mona (Morphine, Oxygen, Nitrate,
Aspirin)

In old patients, MI can be presented as epigastric pain and can be asymptotic❗️

Myocardial infarction symptoms are:
🔺Chest pain ”described as crushing or pressure & radiate to other places.
🔺Can be presented as any of the following: dyspnea, Diaphoresis, weakness, fatigue, vomiting, nausea, syncope

Markers of Ischemia on ECG:
🔹Peaked T waves (early)

🔹ST segment elevation (indicates transmural injury & it is diagnostic)

🔹Q waves (come later)

🔹ST segment depression (Subendocardial injury)

Categories of infarcts
♦️ ST segment elevation infarct: Transmural , include entire thickness of wall and larger.

♦️ Non-ST segment elevation infarct: Subendocardial , include one third of the wall and usually smaller.

Cardiac enzymes differentiate them❗️

Cardiac enzymes are gold standard to diagnose ischemic heart disease
▫️Troponin (I & T): most important, appear within 3-5 hr & become normal within week to two.

▫️CK-M: for recurrent infarct, appear within 4-8 hr & must be repeated every 8 hr.

Complications of acute MI:
🔺Pump failure (CHF)

🔺Arrhythmia (premature ventricular contaction , Afib, PSVT, sinus tachycardia or bradycardia, AV block)

🔺Recurrent infarction

🔺Mechanical complication like free wall rupture or rupture of inter-ventricular septum or papillary muscle.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is excess antidiuretic hormone which leads to water retention & cause: hyponatremia & volume expansion ❗️

Causes of Syndrome of inappropriate antidiuretic hormone secretion (SIADH) are:
▪️Neoplasm (tumor)

▪️CNS disorder (stroke, head trauma ,infection)

▪️Pulmonary disease (pneumonia)

▪️Ventilator with positive pressure

▪️Medication (ex morphine, oxytocin, chlorpropamide, vincristine)