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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)

Most important clinical features of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is hyponatremia whether acute which is less than 48 hr or chronic (more than 48 hr) ❗️

Diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH)is by
🔺Exclusion of other causes of hyponatremia
🔺Looking at the labs (low serum uric acid, bun, creatinine)