Chapter: Ischemic Heart Disease
McMaster Section Editor(s): P.J. Devereaux
Section Editor(s) in Interna Szczeklika: Andrzej Budaj, Wiktoria Leśniak
McMaster Author(s): P.J. Devereaux
Author(s) in Interna Szczeklika: Andrzej Budaj, Anetta Undas
How to Cite This Chapter: Devereaux PJ, Budaj A, Undas A. Ischemic Heart Disease. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.2.5 Accessed February 17, 2019.
Last Reviewed: March 24, 2016
Last Updated: November 14, 2015
Main Documents Taken Into Account:
Authors/Task Force members, Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
Eur Heart J. 2014 Oct 1;35(37):2541-619. doi: 10.1093/eurheartj/ehu278. Epub 2014 Aug 29. PubMed PMID: 25173339.
Task Force Members, Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.
Eur Heart J. 2013 Oct;34(38):2949-3003. doi: 10.1093/eurheartj/eht296. Epub 2013 Aug 30. Erratum in: Eur Heart J. 2014 Sep 1;35(33):2260-1. PubMed PMID: 23996286.
O'Gara PT, Kushner FG, Ascheim DD, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation. 2013 Jan 29;127(4):e362-425. doi: 10.1161/CIR.0b013e3182742cf6. Epub 2012 Dec 17. Erratum in: Circulation. 2013 Dec 24;128(25):e481. PubMed PMID: 23247304.
Fihn SD, Gardin JM, Abrams J, et al; American College of Cardiology Foundation/American Heart Association Task Force. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
Circulation. 2012 Dec 18;126(25):e354-471. doi: 10.1161/CIR.0b013e318277d6a0. Epub 2012 Nov 19. Erratum in: Circulation. 2014 Apr 22;129(16):e463. PubMed PMID: 23166211.
2012 Writing Committee Members, Jneid H, Anderson JL, Wright RS, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
Circulation. 2012 Aug 14;126(7):875-910. doi: 10.1161/CIR.0b013e318256f1e0. Epub 2012 Jul 16. PubMed PMID: 22800849.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, Thygesen K, Alpert JS, White HD, et al; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction.
Eur Heart J. 2012 Oct;33(20):2551-67. doi: 10.1093/eurheartj/ehs184. Epub 2012 Aug 24. PubMed PMID: 22922414.
Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
Eur Heart J. 2012 Oct;33(20):2569-619. doi: 10.1093/eurheartj/ehs215. Epub 2012 Aug 24. PubMed PMID: 22922416.
Hamm CW, Bassand JP, Agewall S, et al; ESC Committee for Practice Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).
Eur Heart J. 2011 Dec;32(23):2999-3054. doi: 10.1093/eurheartj/ehr236. Epub 2011 Aug 26. PubMed PMID: 21873419.
Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
Circulation. 2011 Dec 6;124(23):2574-609. doi: 10.1161/CIR.0b013e31823a5596. Epub 2011 Nov 7. Erratum in: Circulation. 2012 Feb 28;125(8):e411. PubMed PMID: 22064598.
Abraham NS, Hlatky MA, Antman EM, et al; ACCF/ACG/AHA. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents.
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Ischemic heart disease (IHD) comprises all types of myocardial ischemia (ie, reduced blood supply), regardless of the pathologic mechanism.
Coronary artery disease (CAD) is IHD due to atherosclerosis of a coronary artery.
1. Classification of CAD:
1) Stable CAD:
a) Stable angina pectoris.
b) Microvascular angina (syndrome X).
c) Angina associated with myocardial bridging of coronary arteries.
d) Vasospastic angina (Prinzmetal variant angina).
2) Acute coronary syndromes (ACSs).
2. ACS classification based on initial electrocardiography (ECG) findings:
1) Non–ST-segment elevation ACS.
2) ST-segment elevation ACS.
3. Classification of ACS based on clinical manifestations, biochemical markers of myocardial necrosis, and ECG:
1) Unstable angina (UA).
2) Non–ST-segment elevation myocardial infarction (NSTEMI).
3) ST-segment elevation myocardial infarction (STEMI).
4) Unspecified myocardial infarction (MI). ECG abnormalities that do not allow an unequivocal diagnosis of ST-segment elevation: left bundle branch block (LBBB) (acute or preexisting), pacemaker rhythm, or infarction diagnosed on the basis of clinical and biochemical criteria, where an ECG was performed >24 hours after the onset of symptoms.
5) Sudden cardiac death.
4. Classification of MI based on the evolution of ECG features:
1) Q-wave MI.
2) Non–Q-wave MI.
Etiology and Pathogenesis Top
1. Etiology of IHD:
1) Most commonly, IHD is due to coronary atherosclerosis.
2) Less commonly, IHD is due to coronary artery spasm (Prinzmetal variant angina, illicit drug use [eg, cocaine], or discontinuation of nitrates), coronary artery embolism, vasculitis of the coronary arteries, metabolic disorders affecting the coronary arteries, anatomical defects of the coronary arteries, coronary artery injury, arterial thrombosis due to disorders of hemostasis, reduced oxygen supply in relation to demand (aortic stenosis or regurgitation, hypertrophic cardiomyopathy, carbon monoxide poisoning, decompensated thyrotoxicosis, long-standing hypotension, anemia, myocardial bridging), or aortic dissection.
2. Etiology of stable angina pectoris: Stable angina pectoris is usually due to occlusion of an epicardial coronary artery by an atherosclerotic plaque.
Classification of epicardial coronary artery stenosis:
1) Noncritical stenosis: Approximately 50% focal reduction of the coronary artery luminal diameter and ~75% reduction in the coronary artery cross-sectional area. An atherosclerotic plaque causing the occlusion may potentially lead to ACS, but it remains asymptomatic as long as it is stable.
2) Significant subcritical stenosis: Approximately 50% to 75% reduction of the coronary artery luminal diameter. Coronary blood flow may adapt to the demand to some extent, but in the case of a further increase of cardiac output (exercise or pharmacologic stress test, eg, dobutamine), the symptoms of angina will occur.
3) Critical stenosis: Approximately 75% reduction of the coronary artery luminal diameter and >90% reduction of the coronary artery cross-sectional area. Symptoms of myocardial ischemia may occur even at rest.
3. Etiology of ACS: A sudden imbalance between the myocardial oxygen demand and supply, most frequently due to sudden occlusion of a coronary artery by a thrombus formed on a ruptured atherosclerotic plaque.
1) UA most frequently results from rupture of an eccentric plaque. The resulting thrombus reduces coronary blood flow, but the occlusion is not complete.
2) NSTEMI is the result of a process similar to UA and is associated with elevation of troponin levels.
3) In STEMI, the thrombus usually causes a complete and sudden occlusion of a coronary artery. Necrosis starts to develop within 15 to 30 minutes of the cessation of blood flow and spreads from the subendocardium to the epicardium. The rate at which necrosis develops depends on the diameter of the occluded artery and the collateral circulation.