Ischemic heart disease or myocardial ischemia results from blocked coronary artery. Ischemic heart disease symptoms include angina pain and irregular heartbeat.

Ischemic Heart Disease

Humza Khizer

Overview

Ischemic heart disease, also known as coronary heart disease, occurs when a partial or complete blockage of the arteries occludes blood flow to the heart muscle.

The term ischemia means that an organ, for example, the heart, is not getting enough blood and oxygen. Ischemia is simply described as an inadequate blood supply to an area, such as the heart, because of a blockage of a blood vessel supplying the area. Ischemic heart disease is also known as coronary heart disease (CHD) and is caused because of a narrowing of the arteries that supply blood to the heart muscles. The narrowing of the arteries is often caused by a constriction of the arteries because of a blood clot, or buildup of plaque. When blood flow to the heart muscles is constricted, the cells of the heart muscle die. This is referred to as a heart attack or myocardial infarction. If the blocked arteries are left untreated, symptoms may occur especially during emotional stress or exercise as the demand for oxygen being carried by the blood increases.&nbsp;

 
The discomfort that is experienced when the heart muscles are deprived of oxygen is termed angina pectoris, which is characterized by symptoms of chest, arms, jaw, shoulder, and back pain. The symptoms typically aggravate because of emotional or physical stress and are often relieved with rest. <a href="https://www.merisehat.pk/disease/angina" target="_blank">Angina </a>is a common presentation in patients with ischemic heart disease and uncontrolled hypertension.

Ischemic heart disease is a common illness affecting a large part of the population in developed and developing countries. According to the National Health and Nutrition Examination Survey, 17.6 million Americans, 20 years or older were diagnosed with ischemic heart disease from 2003 to 2006<a href="#accordion">[1]</a>. The disease has an overall prevalence of 7.9%, in both men and women with a higher prevalence in men of 9.1% and 7% in women<a href="#accordion">[1]</a>. Ischemic heart disease causes more than half of all cardiovascular events in men and women under the age of 75<a href="#accordion">[2]</a>.&nbsp;

 
The World Health Organization highlights that the number of deaths because of cardiovascular disease in low to middle-income countries has significantly risen over the years. Moreover, developing countries, including Pakistan account for 86% of the global burden of cardiovascular disease<a href="#accordion">[3]</a>.

&nbsp;

The discomfort experienced when the heart muscles are deprived of oxygen, in the case of ischemic heart disease, is known as angina. Angina is chest pain that is not usually life-threatening but is a warning sign of a heart attack or stroke. The Canadian Cardiovascular Society (CCS) scheme grades angina and other equivalent presenting symptoms based on the level of activity.&nbsp; 
&nbsp;

<ul>
	<li>Class I &ndash; Class I <a href="https://www.merisehat.pk/disease/angina" target="_blank">angina </a>occurs when there is rapid or prolonged exertion such as walking 5 miles per hour, playing tennis or squash, skating, skiing, rope skipping, jogging, dancing, cycling, climbing hills, or chopping wood. <a href="https://www.merisehat.pk/disease/angina" target="_blank">Angina</a> is not caused by ordinary physical activity.&nbsp;</li>
	<li>Class II &ndash; Class II angina is characterized by chest pain triggered by ordinary physical activity, for example, climbing up the stairs, walking uphill or up the stairs, or climbing the stairs rapidly. Additionally, this type of angina can also be aggravated by emotional stress, walking in the cold or winter, or walking more than 2 blocks on ground level at a normal pace, in normal conditions.&nbsp;</li>
	<li>Class III &ndash; Class III <a href="https://www.merisehat.pk/disease/angina" target="_blank">angina </a>is also triggered by walking one or two blocks on ground level, climbing stairs in normal conditions at a normal pace, gardening, or performing other household chores.&nbsp;</li>
	<li>Class IV &ndash; Class IV angina is characterized by an inability to carry out any physical activity and symptoms of angina may also be present at rest.</li>
</ul>

&nbsp;

1. Stable Ischemic Heart Disease: Stable ischemic heart disease means that the patient has suspected or has been diagnosed with ischemic heart disease but with no symptomatic changes. Types of stable ischemic heart disease include: 
&nbsp;

<ul>
	<li>Stable-<a href="https://www.merisehat.pk/disease/angina" target="_blank">Angina </a>Pectoris: stable angina pectoris is a type of chest pain that occurs when the heart muscles need more oxygen, for example, when you are exercising or when the weather is cold.&nbsp;</li>
	<li>Vasospastic Angina Or Prinzmetal Angina: vasospastic angina develops when the arteries supplying blood to the heart muscles go into spasms and suddenly narrow.&nbsp;</li>
	<li>Microvascular Angina: microvascular angina, also known as syndrome X is a type of angina that occurs because of problems in the small blood vessels that bring oxygen to the heart. When the heart muscles don&rsquo;t get enough oxygen, they will get damaged and start to die.&nbsp;</li>
	<li>Myocardial Bridging Angina: a myocardial bridge is generally a harmless condition in which one or more of the arteries, instead of lying on the surface, goes through the heart muscle. Myocardial bridging does not usually cause any symptoms except chest pain.&nbsp; 
	&nbsp;</li>
</ul>

 
2. Acute Coronary Syndrome (ACS):&nbsp;The&nbsp;term refers to conditions associated with sudden, reduced blood flow to the heart. It can be classified based on ECG findings as:&nbsp;

<ul>
	<li>Non-St segment elevation&nbsp;</li>
	<li>ST-segment elevation&nbsp; 
	&nbsp;</li>
</ul>

 
3. ACS Classification Based On Clinical Manifestations, Biochemical Markers, And ECG

<ul>
	<li>Unstable angina, is a condition in which the heart is not getting enough blood flow or oxygen&nbsp; &nbsp;</li>
	<li>Non&ndash;ST-segment elevation myocardial infarction&nbsp;(NSTEMI)</li>
	<li>ST-segment elevation myocardial infarction&nbsp;(STEMI)</li>
	<li>ST-segment elevation myocardial infarction&nbsp;(STEMI)</li>
	<li>Unspecified myocardial infarction&nbsp;(MI)</li>
	<li>Sudden death due to a cardiac event</li>
</ul>

 
4. Classification Of Myocardial Infarction Based On ECG Findings

Myocardial infarction or heart attack occurs when one or more areas of the heart muscle are not getting enough oxygen because of blocked blood flow. The types include,

<ul>
	<li>Q-wave MI&nbsp;</li>
	<li>Non-Q wave MI</li>
</ul>

 
5. Silent Ischemia:&nbsp;Many people may have ischemic heart disease without pain, this is known as silent ischemia. In silent ischemia, people may suffer from a heart attack without any warning. People with a history of heart attacks or <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes</a> are at a higher risk of developing silent ischemia.

&nbsp;

Signs And Symptoms

Ischemic heart disease may not present with any symptoms in the early stage of the disease. However, if the heart muscle is not getting enough blood because of ischemic heart disease, people may experience symptoms, including:&nbsp;

<ul>
	<li>Extreme fatigue&nbsp;</li>
	<li>Difficulty breathing, shortness of breath when physically active&nbsp;</li>
	<li>Dizziness&nbsp;</li>
	<li>Lightheadedness&nbsp;</li>
	<li>Fainting&nbsp;</li>
	<li>Tachycardia (fast heartbeat)</li>
	<li>Sweating</li>
	<li>Chest pain&nbsp;</li>
	<li>Shoulder or arm pain</li>
	<li>Swelling in the legs, feet, and abdomen&nbsp;</li>
	<li>Cough and congestion because of fluid in the lungs&nbsp;</li>
	<li>Weight gain&nbsp;</li>
	<li>Nausea and vomiting</li>
	<li>Difficulty sleeping</li>
</ul>

&nbsp;

Causes

Ischemia occurs when the heart is not getting enough blood and oxygen because one or more of the arteries supplying the heart are blocked. The ischemia can either develop slowly or occur quickly depending on the pace at which the arteries get blocked. Causes of ischemia may include:&nbsp; 
&nbsp;

<ul>
	<li><a href="https://www.merisehat.pk/disease/coronary-artery-disease" target="_blank">Coronary Artery Disease</a> (Atherosclerosis): Atherosclerosis is the thickening of the inner lining of the arteries and is the most common cause of ischemia. Atherosclerosis is characterized by a buildup of plaque on the artery walls that restrict blood flow. The risk factors of plaque buildup include high cholesterol, eating saturated fats, physical inactivity, <a href="https://www.merisehat.pk/disease/obesity" target="_blank">obesity</a>, <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes</a>, smoking, and high blood pressure.&nbsp;</li>
	<li>Blood Clot: The plaques that develop can rupture and cause a blood clot, which may block an artery, leading to ischemic heart disease and resulting in a heart attack. However, it is very rare for a blood clot to travel to the coronary artery (artery supplying blood to the heart), from elsewhere in the body.&nbsp;</li>
	<li>Coronary Artery Spasm:&nbsp;The tightening of the muscles in the artery wall can decrease blood flow to a part of the heart muscle. However, this is an uncommon cause of ischemia.</li>
</ul>

&nbsp;

Other common triggers of ischemic heart disease include:&nbsp;

<ul>
	<li>Physical exertion&nbsp;</li>
	<li>Stress&nbsp;</li>
	<li>Cold temperatures&nbsp;</li>
	<li>Use of cocaine&nbsp;</li>
	<li>Eating heavy meals&nbsp;</li>
	<li>Sexual intercourse</li>
</ul>

&nbsp;

Screening helps detect disease before the symptoms begin to show, at its earliest and most treatable stage. Screening tests may include lab tests, including tests for blood and other fluids, and genetic tests to look for genetic markers linked to disease. In heart screening, individuals with no signs and symptoms of ischemic heart disease may be evaluated for:&nbsp; 
&nbsp;

<ul>
	<li>Cholesterol:&nbsp;The amount of cholesterol that is carried by the blood is known as low-density lipoproteins (LDL). High levels of LDL can lead to buildup in the arteries.&nbsp;</li>
	<li>Blood Glucose Levels, which is the amount of sugar in the blood.&nbsp;</li>
	<li>C-reactive Protein (hs-CRP) Assay: C-reactive protein (hs-CRP) assay checks for C-reactive protein in the blood. The level of C-reactive is higher when there is swelling or inflammation anywhere in the body.&nbsp;</li>
	<li>Blood Pressure: Blood pressure is defined as the pressure of blood against the walls of the arteries when the heart beats (systolic) or when it is at rest (diastolic).&nbsp; 
	&nbsp;</li>
</ul>

After initial screening tests and the presence of risk factors of ischemic heart disease, the doctor may recommend additional tests, including:&nbsp;

<ul>
	<li>Electrocardiography (ECG/EKG): Electrocardiography measures electrical activity in the heart, heart rate, and rhythm.&nbsp;</li>
	<li>Cardiac Stress Test Or Exercise Electrocardiogram: A cardiac stress test or exercise involves walking on a treadmill at increasing levels of difficulty and the electrical activity of the heart, heart rate, rhythm, and blood pressure are monitored to check if the blood flow to the heart is adequate when the heart is under physical stress. For people who are unable to exercise, the test is carried out using medication that makes the heart beat faster and harder.&nbsp;</li>
	<li>Echocardiography: Stress echocardiography uses ultrasound to create moving pictures of the heart before and after the heart is stressed either through medication or exercise.&nbsp;&nbsp;</li>
	<li>Cardiac CT For Calcium Scoring: This test is also known as coronary artery calcium scoring and is used to examine the coronary arteries and measure the presence of calcium in the coronary arteries. A high calcium score indicates the presence of plaque in the arteries.&nbsp;</li>
	<li>Coronary CT Angiography (CTA): In this investigation computed tomography (CT) and contrast material or dye are used to create three-dimensional images of the arteries supplying blood to the heart, to determine the location and extent of the buildup of plaque.&nbsp;</li>
	<li>Myocardial Perfusion Imaging (MPI): Also known as a nuclear stress test, in this test a small amount of radioactive material is injected which accumulates in the heart. A special camera is then used to take pictures of the heart while the patient is at rest and following exercise. The test determines the effect of physical stress on blood flow to the heart muscle.&nbsp;</li>
	<li>Coronary Catheter Angiography: In this test, a catheter is inserted into the artery via a small incision. Once the catheter is in, contrast material is injected through a tube and pictures are taken of the blood flow through the coronary arteries using an X-ray which allows visualization of any blockage or narrowing of the coronary arteries.</li>
</ul>

&nbsp;

Diagnosis

Ischemic heart disease is diagnosed based on physical examination and imaging tests. In rare cases, the doctor may biopsy heart tissue to rule out certain diseases. Diagnostic tests for ischemic heart disease include:

 
Physical Exam

In the case of ischemic heart disease, physical examination is significant for:

<ul>
	<li>Crackling sound on auscultation (listening to sounds of the heart, lungs, or other organs using a stethoscope)</li>
	<li>Enlarged liver&nbsp;</li>
	<li>Swelling caused by excess fluid in the legs and ankles&nbsp;</li>
	<li>Increased pressure in the neck vein</li>
</ul>

&nbsp;

Other imaging tests to determine the location and extent of heart disease include:&nbsp;

<ul>
	<li>Echocardiogram:&nbsp;The test will determine decreased ejection fraction, which refers to how well blood pumps with each heartbeat.&nbsp;</li>
	<li>Magnetic Resonance Imaging (MRI): MRI will help determine the ejection fraction.&nbsp;</li>
	<li>Electrocardiogram:&nbsp;Electrodes are attached to the skin to record the electrical activity of the heart.&nbsp;</li>
	<li>Stress Test: The stress test will determine whether blood pressure, heart rhythm, and breathing are normal during physical stress which may not be noticeable otherwise.&nbsp;</li>
	<li>Stress Echocardiogram: A&nbsp;stress echocardiogram is similar to a regular echocardiogram but is done after exercise on either a treadmill or stationary bike.&nbsp;</li>
	<li>Nuclear Stress Test:&nbsp;In this test a small amount of radioactive material is injected into the blood and the doctor watches the flow of blood through the heart and lungs while you exercise. The test helps identify problems with blood flow.&nbsp;</li>
	<li>Coronary Angiography: In coronary angiography, a dye is injected into the blood vessels of the heart and a series of X-ray images are taken for a detailed look inside the blood vessels.&nbsp;</li>
	<li>Cardiac CT Scan: A&nbsp;cardiac CT scan determines whether there is a buildup of calcium in the coronary arteries. 
	&nbsp;</li>
</ul>

Treatment

Treatment for ischemic heart disease centers around the comprehensive management of angina and stable heart disease. The therapeutic approaches include:&nbsp;

<ul>
	<li>Identification and treatment of diseases that may worsen or trigger angina and ischemia.&nbsp;</li>
	<li>Identification and treatment of cardiac risk factors.&nbsp;</li>
	<li>Symptomatic management of angina and ischemia with lifestyle modification, medical therapy, and risk factor reduction.&nbsp;</li>
	<li>Surgical intervention when needed.&nbsp; 
	&nbsp;</li>
</ul>

Medications for the treatment of ischemic heart disease include:&nbsp;

<ul>
	<li>Aspirin:&nbsp;Aspirin and other blood thinners reduce the risk of a blood clot and prevent coronary artery blockage. However, aspirin is not recommended for patients with bleeding disorders and those already taking other blood thinners.&nbsp;</li>
	<li>Nitrates: nitrates widen the arteries and improve blood flow, meaning your heart does not have to work as hard.&nbsp;</li>
	<li>Beta-Blockers:&nbsp;Beta-blockers help relax the heart muscle and slow down the heart rate in addition to decreasing blood pressure so the blood can flow more easily.&nbsp;</li>
	<li>Calcium Channel Blockers: Calcium channel blockers widen the blood vessels and increase blood flow to the heart, thus reducing the workload on the heart.&nbsp;</li>
	<li>Cholesterol-Lowering Medications:&nbsp;The medications decrease the deposit of LDL or bad cholesterol in the coronary arteries.&nbsp;</li>
	<li>Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors are recommended to patients with high blood pressure and diabetes in addition to ischemic heart disease. The medication relaxes the blood vessels, thus also lowering blood pressure. ACE inhibitors may also be used if the heart does not pump blood effectively.&nbsp;</li>
	<li>Ranolazine:&nbsp;The medication helps relax the coronary arteries and ease angina. Ranolazine is often prescribed with other medications such as calcium channel blockers, nitrates, and beta-blockers.&nbsp; 
	&nbsp;</li>
</ul>

In some cases, more aggressive treatment approaches are needed to improve blood flow. The procedures include:&nbsp;

<ul>
	<li>Angioplasty And Stenting: in this procedure, a catheter is inserted into the narrowed part of the artery, and the area is inflated with a tiny balloon to widen the artery. Typically, a mesh coil (stent) is used to keep the artery open.&nbsp;</li>
	<li>Coronary Artery Bypass Surgery (CABG): in CABG, a surgeon uses a vessel from another part of the body and grafts it around the blocked or narrow artery to allow blood to flow. CABG is recommended for patients with several narrowed arteries.&nbsp;</li>
	<li>Enhanced External Counterpulsation: This is a non-invasive outpatient procedure that is recommended when other treatment approaches do not work. In this procedure, cuffs are wrapped around the legs and gently inflated to improve blood flow to the heart.</li>
</ul>

&nbsp;

Ischemic heart disease can lead to serious complications, including:&nbsp;

<ul>
	<li>Heart Attack:&nbsp;If the coronary arteries become completely blocked, there is a lack of blood flow and oxygen that can lead to a heart attack. A heart attack may cause damage to the heart muscle that can be fatal.&nbsp;</li>
	<li>Arrhythmia (Irregular Heart Rhythm):&nbsp;An irregular heart rhythm can weaken the heart muscles.&nbsp;</li>
	<li>Heart Failure: Repeated episodes of ischemia over time may cause the heart to go into failure. 
	&nbsp;</li>
</ul>

Factors that may increase the risk of developing ischemic heart disease include:&nbsp;

<ul>
	<li>Tobacco: Long-term exposure to tobacco through active smoking or exposure to secondhand smoke (passive smoking) can cause damage to the walls of the arteries. The damaged arteries become more vulnerable to deposits of cholesterol and other substances that slow blood flow to coronary arteries. Smoking may also cause the coronary arteries to spasm and increase the risk of blood clots.&nbsp;</li>
	<li><a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">Diabetes Type 1 and 2</a>:&nbsp;Diabetes is linked with an increased risk of ischemic heart disease, heart attack, and other problems related to the heart.</li>
	<li>High Blood Pressure:&nbsp;High blood pressure can overtime increase plaque buildup and cause damage to the coronary arteries.&nbsp;&nbsp;</li>
	<li>High Cholesterol Level: High levels of bad cholesterol in the blood can cause deposits of cholesterol to narrow the coronary arteries. This may be because of a diet high in saturated fats and cholesterol or an inherited condition.&nbsp;</li>
	<li>High Blood Triglyceride: High levels of triglyceride, which is a type of blood fat in the blood can contribute to the buildup of plaque in the walls of arteries.&nbsp;</li>
	<li><a href="https://www.merisehat.pk/disease/obesity" target="_blank">Obesity</a>: Obesity is linked with high blood cholesterol levels, high blood pressure, and diabetes.&nbsp;</li>
	<li>Large Waist Circumference:&nbsp;A&nbsp;waist circumference of more than 35 inches in men and 40 inches in women increases the risk of heart disease, diabetes, and high blood pressure.&nbsp;</li>
	<li>Sedentary Lifestyle:&nbsp;A&nbsp;lack of physical activity leads to obesity which is linked to higher cholesterol and triglyceride levels. People who exercise regularly have better heart health and are at a lower risk of developing ischemic heart disease.</li>
</ul>

&nbsp;

Lifestyle changes are an important part of preventing ischemic heart disease:&nbsp;

<ul>
	<li>Smoking cessation</li>
	<li>Manage underlying health conditions such as diabetes, high blood cholesterol and high blood pressure, and other diseases that increase the risk of ischemic heart disease</li>
	<li>Eat a healthy diet, limit saturated fats, and eat a diet rich in whole grains, fruits, and vegetables</li>
	<li>Exercise regularly to improve blood flow to the heart</li>
	<li>Maintain a healthy weight</li>
	<li>Manage stress with techniques such as muscle relaxation and deep breathing</li>
</ul>

&nbsp;

It is also essential to get regular checkups done if you have a family history or risk factors, for example, diabetes and high blood pressure, or ischemic heart disease. Early detection and treatment can set the stage for better heart health. 
&nbsp;

Key Points

<ul>
	<li>The term ischemia means that an organ, for example, the heart, is not getting enough blood and oxygen. Ischemic heart disease is also known as coronary heart disease (CHD) and is caused because of a narrowing of the arteries that supply blood to the heart muscles.</li>
	<li>Angina is a common presentation in patients with ischemic heart disease. The discomfort that is experienced when the heart muscles are deprived of oxygen is termed angina pectoris, which is characterized by symptoms of the chest, arms, jaw, shoulder, and back pain. The symptoms typically aggravate because of emotional or physical stress and are often relieved with rest.</li>
	<li>Screening helps detect disease before the symptoms begin to show, at its earliest and most treatable stage.</li>
	<li>Treatment for ischemic heart disease centers around comprehensive management of angina and stable heart disease.</li>
</ul>

&nbsp;

[1] Gofman, J.W., Young, W. and Tandy, R., 1966. Ischemic heart disease, atherosclerosis, and longevity. Circulation, 34(4), pp.679-697.

[2] Lloyd-Jones, 2010. Executive Summary: Heart Disease and Stroke Statistics-2010 Update: A Report From the American Heart Association (vol 121, pg 948, 2010). Circulation, 121(12), pp.E259-E259.

[3] Abbas, S., Kitchlew, A.R. and Abbas, S., 2009. Disease burden of ischemic heart disease in Pakistan and its risk factors. Ann Pak Inst Med Sci, 5(3), pp.145-50.

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