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PH-CV11

Ischaemic heart disease

How coronary disease starves the heart in different ways: a fixed narrowing on exertion (stable angina), spasm, a thrombus on a disrupted plaque (acute coronary syndromes), chronic underperfusion and scarring, and sudden cardiac death.

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  • 5 steps · 10 questions
  • 3D anatomy, affected parts marked

By the end, you can

  • Explain how the coronary flow reserve matches supply to demand, and which factors set the heart’s oxygen demand.
  • Relate stable angina to a fixed stenosis and demand ischaemia, and variant angina to coronary spasm.
  • Place unstable angina, NSTEMI and STEMI on one spectrum of plaque disruption and thrombosis, told apart by troponin and the ECG.
  • Distinguish stunned, hibernating and scarred muscle, and explain how chronic ischaemia leads to ischaemic cardiomyopathy and sudden cardiac death.
  • Recognise the classic appearances, classifications and tests of ischaemic heart disease, and explain how each main treatment acts on its mechanism.

What it is

Ischaemic heart disease (coronary heart disease) is a group of conditions in which the blood supply to the heart muscle falls short of its needs, nearly always because of coronary atherosclerosis. It ranges from chronic forms (stable angina and chronic ischaemic heart disease) through the acute coronary syndromes (unstable angina, NSTEMI and STEMI) to sudden cardiac death; less often spasm, an embolus or a tear in a coronary artery is the cause.

5 types to tell apart
Stable angina
Chest discomfort brought on predictably by exertion or emotion and relieved by rest, from a fixed stenosis that cannot let flow rise with demand.
Variant (vasospastic) angina
Transient spasm of a large coronary artery, with pain at rest and transient ST elevation; also called Prinzmetal angina.
Acute coronary syndromes
Unstable angina, NSTEMI and STEMI: a thrombus on a disrupted plaque suddenly cuts flow at rest. They are told apart by whether troponin rises (necrosis) and whether the ST segment is elevated.
Chronic ischaemic heart disease
Progressive weakness of the ventricle from old infarcts and chronic underperfusion (ischaemic cardiomyopathy), usually presenting as heart failure.
Sudden cardiac death
Unexpected death from a cardiac cause, usually within an hour of the first symptoms, most often from ventricular fibrillation in ischaemic or scarred muscle.

US spelling: ischaemic → ischemic.

Normal function

Coronary flow matched to demand

Heart muscle works without pause and takes most of the oxygen out of coronary blood even at rest, so it can meet a higher demand only by increasing flow. Its oxygen demand rises with heart rate, with the tension in its wall (set by the pressure it ejects against and the size of the chamber) and with the force of contraction.

Flow rises because small resistance arterioles within the muscle widen, driven by local signals such as adenosine and by nitric oxide from the endothelium. The large on the surface normally offer little resistance. The difference between resting flow and the most the widened arterioles allow is the coronary flow reserve: in a healthy heart, flow can rise several-fold.

The are squeezed during systole, so flow peaks in diastole. A faster heart rate shortens diastole and cuts the time the has to receive blood. Ischaemic heart disease is anything that leaves this supply short of the demand.

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